I I o I T: Ndian Nstitute F Nformation Echnology Allahabad

Indian Institute of Information Technology Allahabad
(A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)
(A Centre of Excellence in Information Technology)

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA
Ph. 0532-2922025/2431692; Fax. 2431689/ 2430006; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in
Application form for Admission to MBA(IT) and Dual Degree MBA(IT) - Ph.D. Programme 2014
(All fields are mandatory unless otherwise marked. See instructions overleaf for filling the form)
Please mention 1 and/or 2 according to your preference for admission in the box given below:
I. MBA in Information Technology - MBA(IT)
II. Dual Degree MBA(IT)- Ph.D.Program
Either TYPE or fill by hand in CAPITAL Letters
Paste your
Self attested
good quality
color
photograph
here
1. FULL NAME : ______________________________________________

2. Category (Please TICK only) GE
SC
ST
OBC
PH
DPD
SN
NR
FN
Community (only for

OBC minority
candidates)
3. FATHERS NAME : ______________________________ 4. Mothers Name ______________________________

5. DATE OF BIRTH : __________________ 6. Place of Birth : _________________________ 7. SEX : MALE/FEMALE
8. MARITAL STATUS : ______________________ 9. NATIONALITY : _______________________
10. ADDRESS FOR CORRESPONDENCE : _________________________________________________________________
_________________________________________________________________________________________________
______________________STATE : ____________________ PIN CODE : _____________________
11. Phone No./Mobile No :_________________Fax No. (if any) : (_____)____________
E-mail address : ______________________________Alternate E-mail address : _____________________________ (case sensitive)
(Institute is not responsible for any false contact or incomplete contact. E-Mail address should be filled neatly and clearly)
12. Details of Demand Draft (for downloaded/ photocopy/online generated forms only)
Pl. make sure that Demand Drafts issued are MICR TYPE only and payable at Allahabad in favor of IIIT-Allahabad.
a) Amount Rs. .. No. . Dated
b) Bank & Branch issued
13. A. CAT/GMAT
Registration No*.
B. Center Code *
* As in the Admit Card
C. CAT exam details (*) / GMAT Score details for NRI / Foreign Nationals Program
Exam Name
Percentile Score
Exam Month &Year
CAT/ GMAT
14. Qualifying Degree (*) already obtained or in progress

University/
Discipline
Degree
Min. Pass
Institute
Marks % or
Grade Average
15. Working Experience (**) (Latest three only)
Overall % or
Grade Average (if
degree
completed)
Exam Date (in

case of final
year)
Final results
expected by which
year/ NA
Company Name with Full

Address, E-mail & Contact No.
Reporting Office/
Employer, along with
Phone No. & Email ID
Designation
Experience
(Date From To)
16. Declaration by the applicant:

Certified that all information provided by me in this form is correct to the best of my knowledge and belief. I understand that any
willful misrepresentation of facts will result in my admission being cancelled / dismissal from the Institute. If admitted, I shall abide
by all the rules and regulations of the Institute.
Date & Place: __________________________________Signature of Candidate _______________________________________
17. Declaration by Parent/ Guardian
In the event of Mr./Ms. _______________________________ son/ daughter/ ward being admitted, I hereby give an undertaking to
pay regularly all admissible dues to the Institute and Hostel till the completion of his/ her studies. I also undertake the responsibility
for his/ her good conduct. I am also aware that RAGGING is prohibited at the Institute and is treated as a cognizable offence at
IIIT-A under the Indian Penal Code & the directions of Honble Supreme Court of India and will ensure that he/she will not be
involved in any ragging related activity. He/She shall maintain honour and dignity of the Institute.
Date & Place: __________________________________Signature of Parent/Guardian_________________________________
Note:
Applications are subject to screening and shortlisting.
Incomplete form in any respect will be primarily rejected.
Only Hostel & Mess Fees are refundable in case of withdrawal from admission.
(*) Attach attested copies of certificates, mark sheet, etc. see checklist overleaf for certificates required.
(**) A candidate presently working (including those on projects) must provide a No Objection/Relieving Certificate from the
employer.
Recommendation letter from the company in their company letter head & seal are required.
($) Photocopies of this form or copies downloaded from IIIT-Allahabad website (http://www.iiita.ac.in) or online generated forms are
acceptable; however, photocopies or downloaded or online generated forms must accompany the Demand Draft of Rs. 1200/- for
General and OBC (Rs.600/- for SC/ST/PH candidates).
INSTRUCTIONS FOR FILLING THIS FORM
1. Either TYPE or fill in CAPITAL letters by hand.
2. All items marked with an asterisk (*) require you to submit an self attested copy of some document and not the originals.
Documents for which self attested copies are required are given in the checklist.
3. The application fee of Rs. 1200/- for General and OBC (Rs.600/- for SC/ST/PH candidates) must be paid through demand draft
payable to IIIT-Allahabad at Allahabad.
4. The abbreviations of categories are as follows:
SC* : Scheduled Caste; ST* : Scheduled Tribe; OBC* : Other Backward Cast; GN : General, NR* : Non Resident Indian;
PH* : Physically Handicapped; SN* : Sponsored; FN*: Foreign National (including SAARC); DPD*: Armed Forces Personnel
Killed/Disabled.
Checklist (Please circle the enclosed documents).
Send the self attested copies for below mentioned 1 to 6 and original for 7 to 9 please (without which it shall be summarily rejected).
1. Date of birth (DOB) certificate or High School (Class Ten) Certificate with DOB (Required for all candidates)
2. SC/ST/PH/OBC/DPD Certificate if applicable (Item 2)
3. CAT /GMAT score card (Item 13 C)
4. Copies of marks/grade sheets (Item 14).
5. Equivalence Certificate in case Grades are awarded by the Qualifying Degree granting Institution.
6. No Objection/Relieving Certificate from employer (for sponsored candidates only).
7. Medical Examination report.
8. Sponsorship Certificate/Recommendation letter from the company in their company letter head with seal.
9. Three letters of reference (for all GMAT qualified & sponsored applicants)
10. In case of downloaded or photocopied or online generated application form, the form should be enclosed with the DD of MICR
type for Rs.1200/- (General/OBC) or Rs.600/- (SC/ST/PH) as applicable, without which it shall be summarily rejected.
IMPORTANT DATES
Date of GD & Personal Interview (at IIIT-Allahabad only) for screened in applicants
for MBA( IT) and Dual Degree MBA(IT) - Ph.D.
: 12th April 2014.
( Please visit our website for regular updates and for any entrance test schedule changes)
Please send the complete filled in application to : The Asst. Registrar (Exam), Indian Institute of Information Technology
Allahabad, Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA.
Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable.
SPONSORSHIP CERTIFICATE
(for sponsored candidates only)
(This should be typed on the original letterhead of the Sponsoring Organization and enclosed with application
for admission).
To,
The Director,
Devghat, Jhalwa,
Allahabad -211 012 (U.P.), INDIA
Sub :
Sponsoring of our employee for MBA(IT)/ Dual Degree MBA(IT)-Ph.D. Program at IIITAllahabad.
Dear Sir,
We hereby Sponsor the candidature of Mr. / Ms. _____________________________________ working
as______________________________in our organization, for joining as a full time candidate for MBA(IT)/
Dual Degree MBA(IT)-Ph.D. Programme at your Institute.
He/ She have been employee of our organization for ____________________years.
We shall bear the total expenses of his/ her studies. We shall fully relieve him/ her of his/ her duties in the
organization during the entire study period of the program. The candidate would do the summer training in the
sponsor organization and will rejoin the organization after the study period gets over.
We also certify that his/ her conduct at our organization has been good.
Signature and Seal of

The Sponsoring Authority
Date:
Phone/Mobile No..
E-Mail ID..
(Note: Sponsoring authority should be DGM/GM/Honble position holders)

(A University Established under Sec. 3 of UGC Act, 1956 vide Notification No. F.9-4/99-U.3 Dated 4/8/2000 of the Govt. of India)
(A Centre of Excellence in Information Technology)

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA
Ph. 0532-2922025/2431692; Fax. 2431689/ 2430006; Web: www.iiita.ac.in; E-mail: contact@iiita.ac.in
(Applicable only for Sponsored / GMAT Applicants)

CONFIDENTIAL
LETTER OF REFERENCE
Note to the Candidate:
Please give this form to a referee who can help us with his assessment of your academic potential for pursuing ... in
your desired field of study. The referee may be requested to mail it directly to us after filling it. Please however fill in your
name & desired program of study, before handing this form over to the referee;
Name of the Applicant (Surname First)
Program to which admission is sought

1) MBA(IT)
2) Dual Degree MBA(IT) - Ph.D.
Note for Referee:
To help us in the appraisal of the candidates case for admission to a Post graduate programme at IIIT-Allahabad, you are
requested to fill in the following information to the best of your knowledge. This information will be treated as strictly
confidential.
1.
I have known the applicant for past ___________________ years.
2.
My knowledge of this student is based on (please tick):

Having him/ her in one or more courses.
Knowing him/ her personally
Supervision of his/ her thesis/ project
Inquiry and discussion with my colleagues
3.
Interaction with him/ her in connection with his/ her conference Paper
Presentation/ Project/ other Technical Discussions
Performance in my Courses (in case you have taught him):
Course Title
No. of Students
Grade
Remarks
4.
The candidate ranks approximately ___________ in a class of about __________ students (in case you have
taught him).
5.
A note on general observations

about the candidate including
his/ her professional achievement,
etc.,
if
any
(Please attach separate sheet, if required.)
6.
My rating of the candidate in Following trials (please tick):

Excellent
Good
Fair
Unable to judge
Analytical Ability
Experimental Skills
Motivation
Written and Oral Expression
Leadership & Initiative

Teaching Ability
Sincerity & Dedication

7. To summarize, I would like to say that the applicant (please tick) :
is likely to become a brilliant scholar or an outstanding leader in his/ her chosen field.
is likely to do very well in the Post Graduate programme.
is likely to perform satisfactorily.
is not a good prospect.
8.
My recommendation:
I recommend him/ her enthusiastically
I recommend him/ her
I do not recommend him/ her
Name of the Referee ________________________________ Signature ________________________________

Designation/ Position _______________________________ Date ____________________________________
(with Name & Address
of Organization)
________________________________________________________________________
Address
________________________________________________________________________
_________________________ Pin Code__________Fax : ____________________
Telephone No. (with STD code) _______________ (Office)______________(Cell)_________________

Professional qualification of the Referee _________________________________________________________
Please mail this form directly to : The Asst. Registrar (Exam), Indian Institute of Information Technology Allahabad
Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA.

Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable.
IIIT-ALLAHABAD 2014
MEDICAL EXAMINATION REPORT

GENERAL EXPECTATIONS
Candidates will have good general physique with
a)
b)
c)
Normal vision. In case of defective vision, it should be corrected to 6/6 in both eyes.
Normal Hearing. Defective hearing should be corrected.
Normal Heart and lungs and having no history of mental disease or epileptic fits.
PERSONAL HISTORY
1.
Name
2.
Parent/ Guardians Name:

(a) Fathers Name .
(b) Mothers Name .
3.
Age: Years .. Months
4.
Sex:.. Blood group
5.
Identification Marks on the Body:

(This can be a mole or scar)
Major illness / operation:
6.
(Specify nature of illness / operation.)
7.
Allergies if any:
8.
Any Chronic illness for which he/she is taking treatment: .

(Eg. Diabetes, Asthma, Epilepsy, Kidney disease, Bleeding disorder, etc.)
9.
Any kind of disability:
MEDICAL CERTIFICATE
(To be issued by qualified doctor not less than MBBS)
(The following are to be filled by the Medical Officer conducting the medical examination at the candidate side.)
1.
Height :cm.
2.
Weight:kg.
3.
Skin ..
4.
Ears/Hearing:
5.
Vision without glasses :

a)
Right eye : ..
Left eye :.
b)
Colour Blindness :
c)
Correction of vision through glass if any please specify :
6.
Respiratory system :
7.
Nervous system :
8.
Heart :
9.
Abdomen :
a)
Sounds :..
a)
Liver: .
b)
Murmur :.
b)
Spleen :
10. a) Hernia :
11.
b) Hydrocele :
Any other health issue :
12.
Basic Path. Investigations (includes Blood Exam and Urine Testing:Hb, TCL, DLC, FBS, Urine-R &
M, GPRH):.
(From a certified & recognized lab or it can be taken from the IIITA health centre for which Rs.250/- will be charged
additionally.)
___________________________
Signature of the Medical Officer
____________________________
Signature of the Candidate
Full Name :.
MCI Registration No.
Official Seal :.
Date :
MEDICAL CERTIFICATE
(To be issued by IIIT-A Health Centre in Allahabad. Not to be filled by candidate)
Certified
that .
son/daughter of
a)
b)
Fulfills the prescribed standard of physical fitness and is FIT for admission to MBA(IT)/ Dual Degree
MBA(IT)-Ph.D. Program offered by IIIT-A.
does not fulfill the prescribed standard of physical fitness and is unfit / temporarily unfit to admission
due to following defects :
--------------------------------------------------Signature of the Medical Officer at IIIT-A
Declaration
I hereby declare that I am not suffering from any disease other than mentioned in the medical
report. In case if any other disease is found for which I am taking treatment for long time and that is
not reported to the Institute at the time of admission then the Institute will not bear the cost of
treatment.
_______________________
Signature of the Candidate
Note: Institute is not liable for the chronic disease treatment which required the prolonged/ lifelong
treatment.
7

I I o I T: Ndian Nstitute F Nformation Echnology Allahabad

Uploaded by

Copyright:

Available Formats

I I o I T: Ndian Nstitute F Nformation Echnology Allahabad

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

I I o I T: Ndian Nstitute F Nformation Echnology Allahabad

Uploaded by

Copyright:

Available Formats

Indian Institute of Information Technology Allahabad

(A Centre of Excellence in Information Technology)

Either TYPE or fill by hand in CAPITAL Letters

1. FULL NAME : ______________________________________________

Community (only for

3. FATHERS NAME : ______________________________ 4. Mothers Name ______________________________

14. Qualifying Degree (*) already obtained or in progress

15. Working Experience (**) (Latest three only)

Exam Date (in

Company Name with Full

16. Declaration by the applicant:

Signature and Seal of

Indian Institute of Information Technology Allahabad

(A Centre of Excellence in Information Technology)

(Applicable only for Sponsored / GMAT Applicants)

Program to which admission is sought

I have known the applicant for past ___________________ years.

My knowledge of this student is based on (please tick):

A note on general observations

My rating of the candidate in Following trials (please tick):

Leadership & Initiative

Sincerity & Dedication

Name of the Referee ________________________________ Signature ________________________________

Telephone No. (with STD code) _______________ (Office)______________(Cell)_________________

Devghat, Jhalwa, Allahabad -211 012 (U.P.), INDIA.

MEDICAL EXAMINATION REPORT

Parent/ Guardians Name:

Age: Years .. Months

Sex:.. Blood group

Identification Marks on the Body:

Major illness / operation:

(Specify nature of illness / operation.)

Any Chronic illness for which he/she is taking treatment: .

Any kind of disability:

Vision without glasses :

Correction of vision through glass if any please specify :

Any other health issue :

--------------------------------------------------Signature of the Medical Officer at IIIT-A

You might also like

3. FATHERS NAME : 4. Mothers Name

Name of the Referee Signature

Telephone No. (with STD code) _ (Office)(Cell)_____