Please mention 1 and/or 2 according to your preference for admission in the box given below: I. MBA in Information Technology - MBA(IT)

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1 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 (U.P.), INDIA Ph / ; Fax / ; Web: 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 1. FULL NAME : 2. Category (Please TICK only) GE SC ST OBC PH DPD SN NR FN Community (only for OBC minority candidates) 3. FATHER S NAME : 4. Mother s 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) : ( ) address : Alternate address : (case sensitive) (Institute is not responsible for any false contact or incomplete contact. 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 Paste your Self attested good quality color photograph here 14. Qualifying Degree (*) already obtained or in progress University/ Institute Discipline Degree Min. Pass Marks % or Grade Average Overall % or Grade Average (if degree completed) Exam Date (in case of final year) Final results expected by which year/ NA 15. Working Experience (**) (Latest three only) 1

2 Company Name with Full Address, & Contact No. Reporting Office/ Employer, along with Phone No. & 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 Hon ble 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 ( 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. : 12 th April ( 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 (U.P.), INDIA. Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable. 2

3 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, Indian Institute of Information Technology Allahabad Devghat, Jhalwa, Allahabad (U.P.), INDIA Sub : Sponsoring of our employee for MBA(IT)/ Dual Degree MBA(IT)-Ph.D. Program at IIIT- Allahabad. 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. Date: Signature and Seal of The Sponsoring Authority (Note: Sponsoring authority should be DGM/GM/Hon ble position holders) Phone/Mobile No.. ID.. 3

4 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 (U.P.), INDIA Ph / ; Fax / ; Web: contact@iiita.ac.in (Applicable only for Sponsored / GMAT Applicants) LETTER OF REFERENCE CONFIDENTIAL 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 candidate s 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 Interaction with him/ her in connection with his/ her conference Paper Presentation/ Project/ other Technical Discussions 3. 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 4 (Please attach separate sheet, if required.)

5 6. My rating of the candidate in Following trials (please tick): Analytical Ability Excellent Good Fair Unable to judge 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) : 8. My recommendation: 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. 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 (U.P.), INDIA. Note: Kindly write Application for MBA(IT)/Dual Degree MBA(IT) - Ph.D. on the envelope as applicable. 5

6 IIIT-ALLAHABAD 2014 MEDICAL EXAMINATION REPORT Candidates will have good general physique with GENERAL EXPECTATIONS a) Normal vision. In case of defective vision, it should be corrected to 6/6 in both eyes. b) Normal Hearing. Defective hearing should be corrected. c) Normal Heart and lungs and having no history of mental disease or epileptic fits. PERSONAL HISTORY 1. Name 2. Parent/ Guardian s Name: (a) Father s Name. (b) Mother s Name. 3. Age: Years.. Months 4. Sex:.. Blood group 5. Identification Marks on the Body: (This can be a mole or scar) 6. Major illness / operation: (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

7 6. Respiratory system : 7. Nervous system : 8. Heart : 9. Abdomen : a) Sounds :.. a) Liver:. b) Murmur :. b) Spleen : 10. a) Hernia : b) Hydrocele : 11. 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) 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. b) 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