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Indian Institute of Management, Ahmedabad: Nomination Form

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Indian Institute of Management, Ahmedabad

NOMINATION FORM
Programme Title
Date
Please return this completed form to:
Manager (MDP)
Indian Institute of Management, Ahmedabad 380 015
Phone: 91-79-66324072-7  Fax: 91-79-26300352  Email: mdp@iimahd.ernet.in

TO BE FILLED IN BY THE NOMINEE

First Name: Last Name:


Male Female Age Date of Birth
Designation:
Position of Nominee CEO/MD Senior Mgt. Middle Mgt. Junior Mgt.
Organization:
Office Address:

City Pin Fax


Phone (Office): (Residence):
Email Mobile
Description of present responsibilities

Designation of executive to whom you report


Qualification
Degree Subject(s) Year College/University

Work experience
Organization
Position Years of experience Gross Salary
(start with current)

Previous IIMA programmes attended


Programme title Duration Year

Other programmes attended


Institution Programme title Duration Year

What are your expectations from this programme


Date:___________________ Signature:__________________

TO BE FILLED IN BY THE SPONSOR

Name of the sponsor Designation


Organization
Tax Deduction Account Number (T.A.N.)

Permanent Account Number (P.A.N.):

Office Address

City PIN
Phone Fax Email
Information on Organization
Total assets (last year) Total sales turnover (last year)
Major products /
services
Form of Others (specify)
Public Public
Proprietary Partnership
organization Sector Ltd.

Date:___________________ Signature:__________________

Please indicate the sources of information of this MDP


 Advertisement (Please specify): __________________
 Brochure Received by Post (Yes / No): ______________
 From Website: ______________
 Email Received from MDP: ________________________

Payment Details: Cheque / DD No.___________ Date ___________ Amount __________


Bank ______________________________________________________

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