D.H. Road,Jos Brothers Building, Jos Jn., Kochi - 682016.
Ph. : 0484 2362183, 2364183, 2368183. Mob. : 8157860361,E-mail : [email protected] www. iimscochin.com
Door No : 68D, Munnar - Adimaly Road, Near Anachal Petrol Pump, Anachal , Munnar - 685565
Phone : 04865 298183, 9074543320, 6282582735, Email : [email protected]
Kimi Building, Palakkad - Malampuzha Road, Near Fantasy Park, Malampuzha, Palakkad- 6788651
Phone : 0491 2815183 , 9995007729 , 6282587294. Email : [email protected]
APPLICATION FORM
ENROLMENT FORM NO.
COURSE ENROLLING FOR
CENTRE OPTED
Name ..................................................................................................Male/ Female................
Date of Birth......................................Place .......................................Nationality.......................
Caste................................................Religion............................................................................
Current Address ( for communication).......................................................................................
.......................................................................................District................................................
Pin........................................State.........................................Mobile No...................................
Permanent Address..................................................................................................................
City............................................Pin............................................State......................................
Passport No..................................Tel No..............................Mobile No....................................
Parent’s / Guardian’s Name.......................................................................................................
Occupation...............................................................Annual Income (Rs)..................................
Address......................................................................................................................................
Pin.........................State.................................Tel...............................Mobile..............................
Reference ( to Prominent citizens from neighbourhood)
1) Name.................................................................................................................................
Occupation..........................................................................Tel.........................................
Address..............................................................................................................................
II) Name..................................................................................................................................
Occupation..........................................................................Tel...........................................
Address................................................................................................................................
HOSTEL FACILITY - Required / Not Required
School / College attended Last
Name of Instiution Course Attended From (Year) To(Year) Passed or Failed
Professional Training / Practical Exparience, if any (from most recent)
Nature of Work / Designation Employers From To
Sl.No Languages Known Read Write Speak
MotherTongue.................................................................................................................................
How did you come to know about this course.................................................................................
........................................................................................................................................................
Reason for choosing this course....................................................................................................
.......................................................................................................................................................
Reference in IIMS ( if any )............................................................................................................
.......................................................................................................................................................
What are you planing to do after completion of this course. ?
job consultancy own project higher studies
This is to affirm that all information given above is true and that I have read and accepted the tearms and conditions.
Signature of Parent / Guardian
Date.
Signature of student
