Mba 2009

Application No. :

GOVT. OF KARNATAKA

POST GRADUATE COMMON ENTRANCE TEST - 2009

MBA

APPLICATION FORM FOR ADMISSION TO POST GRADUATE PROGRAM IN MASTER OF BUSINESS ADMINISTRATION (MBA) PGCET RANK 1. TEST PLACE :

2. COUNSELING PLACE : (Tick only one)

OFFICE USE

BANGALORE

BELGAUM

OFFICE USE

(See Test Places on page 2)

(in block letters as per Degree M a r k s C a r d )

0 9 M B A

Seat No.:

3. FIRST NAME :

Affix recent colour photograph for scanning

MIDDLE NAME :

25 mm x 35 mm size

LAST NAME :

4. Course applied for (Tick

MBA Part time MBA Full time MBA Infrastructure Management

3 the appropriate box) :

5. Have you applied for PGCET 2009 MCA Test also? Yes 6. Date of Birth :

D

D

M

M

Y

Y

Y

No

7. Sex :

Y

Both

M

F

8. Correspondance Address : ________________________________________________________________ ________________________________________________________________ Signature of the candidate for scanning Test Centre : ________________________________________PIN ____________________ : ( STD Code )___________________________ Cell : _______________________________ E-mail : _____________________________________ __________________ 9. Domicile as per Definition (a) in Brochure 10.Category : (applicable to Karnataka students only) (Tick the appropriate box)

3

11.Qualification Details : Sl. No.

1

Particulars of Examinations passed

I Year

/

I Semester

II Year

/

III Semester

3 the appropriate box) : Karnataka

Non Karnataka

(Tick

GM

SC

ST

IIIA

IIIB

Phy.H.

I

USE

IIA

IIB

Ex-serviceman

Degree : _____________________ Branch / Stream : __________________________ Name of the University with place

Month & Year of passing

*Max. Total Marks

*Marks Obtained

Remarks

II Semester

2 3

OFFICE

IV Semester III Year /

V Semester VI Semester

IV Year 4

/

VII Semester VIII Semester

*Total Marks & Marks obtained should include Optional & Languages also. TOTAL Note : If results are awaited for particular semester indicate “RA” in remarks column. 12. DD Details : Amount : _____________ DD No. _____________________ DD Date : _____________ Name of the drawee Bank _____________________________________________________________________

13. DECLARATION BY THE CANDIDATE 1. I declare that all the information given by me is true and authentic to the best of my knowledge and belief. 2. I have read the instructions carefully and agree to abide by the rules and regulations of admissions. 3. I am fully aware that INCOMPLETE APPLICATION will be rejected by PGCET Cell.

PLACE : D AT E :

Signature of the Candidate

ENCLOSURES CHECK LIST Attested copies of : Statement of marks cards :1) SSLC/10th standard equivalent (specify) 2) PUC/ 10+2 equivalant (specify) 3) Degree (All the years /semesters in full). Study certificate for 7 years of study in Karanataka (See Definition a in Brochure). Income certificate, if claiming admission under reserved category. Authentic documents certified by the Tahasildar / Competent Authority for claiming admission under reserved category. Document in proof of Date of Birth. Experience Certificate (Minimum 3 years), if applying for Part Time.

% Marks Eligible Not Eligible Result Awaited OFFICE

USE

Verified by : (Sign. & Date) 1. ________________________ 2. ________________________

ANNEXURE-POSTAL ADDRESS (for posting admission ticket)

To,

PIN From : The Member Secretary, CPAC & Registrar Visvesvaraya Technological University, “Jnana Sangama”, Belgaum - 590 018. Karnataka State

Cell / Phone No.

FOLLOWING PAGE TO BE RETAINED BY THE STUDENT TEST PLACES Choose any one of the following places where you wish to appear for the test 1 2 3 4

BAGALKOT BANGALORE BELGAUM BELLARY

5 6 7 8

BIJAPUR DAVANGERE DHARWAD GULBARGA

9 10 11 12

HUBLI MANGALORE MYSORE SHIMOGA 13 TUMKUR

IMPORTANT NOTE : 1.

A DD of Rs. 600/- (Rs. 300/- in case of Karnataka SC/ST & Cat-I on production of documentary proof) in favour of member Secretary, CPAC, payable at Belgaum, should be sent along with each Application form.

2.

Application forms for MBA and MCA courses are separate. Candidates who wish to apply for both should apply separately with all enclosures specified, attached with each application.

3.

Write your complete postal address in ANNEXURE POSTAL ADDRESS above to enable PGCET to send a copy of the brochure and Admission Ticket to you.

4.

DO NOT WRITE IN THE SHADED AREAS OF THE APPLICATION FORM, IT IS MEANT FOR OFFICE USE ONLY.

5.

The Candidate will be allowed to write the test, only on production of the Admission ticket.

6.

Admission Ticket, Provisional Admission Order and receipt for the fee paid at PGCET cell are ESSENTIAL as they should be produced for taking admission in the allotted college.

7.

For detailed information about counselling centres and merit list visit www.vtu.ac.in / pgcet.vtu.ac.in For any clarification contact at 0831-2498126 or 0831-2498127

8.

The • • •

following documents should be sent to the address below on or before 05/06/2009 Completed APPLICATION FORM with all enclosures. D.D. of Rs. 600/- (Rs. 300/- for Karnataka SC/ST & Cat-I Candidates only) ANNEXURE POSTAL ADDRESS FOR POSTING ADMISSION TICKET

The Member Secretary, CPAC & Registrar, PGCET CELL Visvesvaraya Technological University, “Jnana Sangama”, Belgaum - 590 018, Karnataka State