INDIAN INSTITUTE OF MANAGEMENT KOZHIKODE
Post Graduate Programme in Management 2019-21
Personal Data Form
Instructions for completion of Personal Data Form
1. This data form is to be submitted online and a printout (1 copy) must be produced at the time of Interview.
2. This data form is a key element of admission process. Complete and accurate reponses to the items are, therefore,
extremely important. Incomplete or false information will adversely affect your chances of selection. Admission granted
on the basis of false information will be ipso facto null and void.
3. In all matters relating to admission to the programme, the decision of the Institute will be final and binding on the
candidate.
SECTION 1: PERSONAL DATA
CAT Regn. No 8151216
CAT Score Card Uploaded
Interview Centre Mumbai
Name (As per CAT
PUSHKAR PACHPOR
application)
CONTACT DETAILS FOR FUTURE COMMUNICATIONS
Address D-307,VJTI Hostel,VJTI,
Near five gardens,
Matunga East,Mumbai
Pin Code 400019
Phone No. Nil
Mobile No. 9022318005
SECTION 2: ACADEMIC RECORD
(A) Schooling
% of
Year of
Standard Board/University Discipline Class/Division Marks Marksheet
completion
Obtained
Maharashtra State Board of
10th Secondary and Higher Secondary 2012 90.92 Uploaded
Education
Maharashtra State Board of
HSC Secondary and Higher Secondary 2015 Science 89.23 Uploaded
Education
(B) Graduation
i) DEGREE ONE
In Case of
Engg.
Degree Name Discipline Subject College University Marksheet Certificate
specify
branch
BE Engineering/Technology Veermata Mumbai Uploaded Uploaded
Jijabai University
Technological Maharashtra
Institute
Year Year of Examination Percentage Score
1st Year 2016 68.1
2nd Year 2017 66.7
3rd Year 2018 71.7
4th Year
5th Year
Bachelor's percentage filled in CAT 2018 application : 68.90
Bachelor's percentage as on January 15, 2019 : 68.9
Whether you have completed your Graduation? NO
Certificate from the Head of the Institution in the prescribed format (Click here). Uploaded
ii) DEGREE TWO
In Case of
Degree Name Discipline Subject Engg. specify College University Marksheet Certificate
branch
Not Not
Uploaded Uploaded
Year Year of Examination Percentage Score
1st Year
2nd Year
3rd Year
4th Year
5th Year
Bachelor's percentage filled in CAT 2018 application :
Bachelor's percentage as on January 15, 2019 :
Whether you have completed your Graduation?
(C) Professional Qualification (CA/ICWA/CS) (As per CAT 2018 application)
Year of Commencing: Nil
Year of Passing: Nil
Professional Inter Percentage filled in CAT 2018 application: Nil
Professional Final Percentage filled in CAT 2018 application: Nil
Marksheet: Not Uploaded
Certificate: Not Uploaded
(D) Professional Certification (CFA - Level 1, 2, 3)
Whether you have received any CFA certification? NO
If yes, please state the CFA level you have qualified: Nil
Year of Passing of the Highest Level: Nil
Percentage Obtained at the Highest Level: Nil
Marksheet: Not Uploaded
Certificate: Not Uploaded
(E) Post Graduation Qualification
Whether you have Post Graduation? NO
SECTION 3: WORK EXPERIENCE
FULLTIME REMUNERATIVE WORK EXPERIENCE AFTER GRADUATION/BACHELOR'S
(Do not include training or project work done as part of any curricular requirement)
Number Designation of
From To Gross Monthly
Organisation Designation of person last Certificate
(Month/Year) (Month/Year) Remuneration
Months reported to
Total relevant work experience in months as on January 31, 2019: 0 months
SECTION 4: EXTRA CURRICULAR ACTIVITIES
1. What are your achievements in Academic, Co-curricular and Extracurricular activities?
Level (a) Academic: (b) Co-curricular: (c) Extracurricular:
State Level: Nil Nil Nil
National Level: Nil Nil Nil
International Level: Nil Nil Nil
DECLARATION
I hereby declare that the details furnished above are true and correct to the best of my knowledge. In case any of the
above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for
it.
I Accept the declaration
Date: 18-02-2019 Name: PUSHKAR PACHPOR
Place: Mumbai
Indian Institute of Management Kozhikode - Personal Data Form 2019
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