Batch Month & Year of Course Commencement

MM 07 YYYY 2011

Registration Number (To be filled by CII-IL)

Confederation of Indian Industry

Since 1895

INSTITUTE OF LOGISTICS (Recognized By Distance Education Council)

APPLICATION FOR ADMISSION

Affix your recent Passport Size Photograph

Tick ( )the program applied for : PG Diploma in supply Chain Management

Regular Admission to Module 1

Certificate in General Management Certificate in Logistics Management

PG Diploma in supply Chain Management

Direct Admission to Module 3

Certificate in Supply Chain Management Advanced Certificate in SCM Advanced Certificate in General Management

Advanced Diploma in SCM Diploma in Supply Chain Management

Note: Read the Prospectus and instructions carefully before filling in.

Mark all entries in English in your own handwriting in BLOCK LETTERS. Tick appropriate boxes and codes wherever applicable. Incomplete application will not be processed. Name of the Applicant: _________________________________________________________________________________________ Age & Date of Birth : __________________________________________________________________________________________ Gender Designation : _________________________________ Nationality: __________________________________________ : _________________________________________________________________________________________

Name of the Organization: ____________________________________________________________________________________ Total Experience (in years): __________________________________________________________________________________ If company sponsored, please furnish company contact details. Contact Person Name Designation E mail id Contact Number

Residential Address

City Pin Code Mobile E mail Alternate E mail Mailing Address (if different from the above)

State Phone

City Pin Code Mobile E mail Alternate E mail

State Phone

Details of Educational Qualification (Degree / PG Degree) Qualification University / Institute Month/ Year of Passing Aggregate Marks %

PAYMENT DETAILS: (Applications without Demand Draft will not be considered) All payments must be made only by Demand Draft drawn in favor CONFEDERATION OF INDIAN INDUSTRY payable at Chennai DD may be obtained from any nationalized private bank in India. Applicants name should be written on the backside of the DD. DD No _______________________________________________ Date _____________________ Amount _______________________ Bank _________________________________________________ Branch ___________________________________________________

DECLARATION I ______________________________________________ hereby solemnly and sincerely affirm that the statements made and the information furnished in the application form, as also in all enclosures thereto, submitted by me are true. I have read and understood the contents of the prospectus and undertake to abide by the norms prescribed by CII-IL from time to time. I understand that I need to visit CII-IL website frequently and watch the notice board therein for general notification for which individual communications will not be sent CII-IL. I understand that it is my responsibility to furnish my email id which is operational and undertake to look for communications from CII-IL periodically. I understand that my responsibility to follow the schedule published by CII-IL from time to time and I shall not expect individual reminders.

Signature of the applicant _____________________________ Place: ___________________________________ Date ____________________

LIST OF ENCLOSURES:
Demand Draft No: ________________________________ Photographs

Self attested copies of the following certificates Degree / Diploma / Provisional Certificate PG Degree/Provisional PG Degree Sponsor Certificate in from employer (optional) Entrance Exam Score Card (Only for Admission to PGDSCM) PG/Degree/Diploma Marks Statements Experience Certificate (optional) Other Certificates

FOR CII-IL OFFICE USE ONLY Entrance Exam Details: (for PGDSCM only) Title of Entrance Exam: _________________________________________________________________________________________ Held on (date): ___________________________________________________________________________________________________ (Marks Scored: ___________________out of___________________) In percentage: ___________________________________

Approved & granted Provisional admission in

PG Diploma in Supply Chain Management Module (Semester) : 1/3

Advanced Diploma in Supply Chain Management Diploma in Supply Chain Management

Certificate in General Management Certificate in Logistics Management Certificate in Supply Chain Management

Certificate in Advanced Supply Chain Management Certificate in Advanced General Management

Reasons if rejected:

Signature of CII-IL official Date: