PGDM-PT

Surname*:

First Name*:

Middle Name:

DOB(DD/MM/YYYY)*:

Age (in years):

Age (in months):

Photo* (upto 600 by 800 pixels dimensions, max 500kb file size)

Address*:

Telephone Number:

Mobile Number*:

Fax Number:

Email Address*:

If address is same as above.

Address*:

Telephone Number:

Mobile Number*:

Address*:

Telephone Number:

Mobile Number*:

Fax Number:

Email Address:

Country*:

	Year of Passing	Main Subjects	Name of School/College/University	Place/City	Percentage
X*
XII*
College (Degree)*
Others

Others: Other academic Degrees/ Master degree/Diplomas (Please specify).

Organisation	Place	Nature of Work	From Day/Month/Year	To Day/Month/Year





Total Experience in Years and Months (Numerics):

(Submitted to Goa Institute of Management , as required for the admission to PGDM-PT)

I, the undersigned, solemnly affirm that:

I have a degree recognized by UGC/ AIU/ AICTE.
I have at least 50% aggregate marks at graduation.
Note: You are requested to carry your letters/certificates/documents, during the admission proccess

Note: You are requested to carry your letters/certificates/documents, during the admission proccess.

I certify that the information given on the Application Form is true to the best of my knowledge and belief.

Date: 04-07-2020