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48 B, KNOWLEDGE PARK III, GREATER NOIDA, NCR, INDIA

Ph. No. 0120-2323823, 2323824, 2323825, Fax No.0120- 2323900


URL: WWW.SRIRAM.AC.IN
MANAGEDBY: UDAAR BHARTI SOCIETY
APPROVED BY: A.I.C.T.E (MINISTRY OF HRD, INDIA)
_______________________________________________________________________________________________________________________________

APPLICATION FORM FOR MBA/PGDM FULL-TIME 2YEARS PROFGRAMME

PERSONAL DETAILS
AGRAWAL
AKASH
Name of the Applicant: Last Name:.. First Name:
23-01-1988
TWENTY THIRD JANUARY NINTY
EIGHTY EIGHT
Date of Birth: In Words
INDIAN
YES
Nationality: Category: GENOBC...SCST
4\693 VIBHAV KHAND GOMTI NAGAR LUCKNOW-226010
Permanent Address: .........................

9044412354
akashagrawal990@gmail.co
Mobile No. :Tel. No.:.E-mail : .
4\693 VIBHAV KHAND GOMTI NAGAR LUCKNOW-226010
Correspondence Address:
9044412354
akashagrawal990@gmail.com
Mobile No.: Tel No.: .E-mail :..
9451471722
Emergency Contact No.: .
Sanwara agrawal
50
m.com
Fathers Name; Age: Qualification: .
Govt officer
auditor
Fathers Occupation: Designation:
9451471722
660000
Mobile No.: Office No.: ...Annual Income:
Seema agrawal
45
ma
Mothers Name: Age:Qualification:
House wife
Mothers Occupation:...Designation:
9024536044
Mobile No.: Office No.: Annual Income:

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EDUCATIONAL QUALIFICATIONS
(Please Attach photocopies of all academic mark sheets)
Name of
Course
10
12

Name of
School/University
Mg inter college
Mg inter college

Name of
Board/Degree
Up board
Up board

Subjects

Year of Passing

science
science

Aggregate %
Obtained
55
55

btech

Dept of engg

Iase university

biotechnology

68

2011

2004
2006

PREQUALIFYING EXAMINATION
(Please Attach Photocopies of Score Cards as Applicable)
Examination
UPSEE

Date of Appearance
April 2012

Enrollment No.
3842236

Score/Percentile/Rank
192/2469

MAT CAT..
Any Other..

May 2012

207220418

638.5/81.38

Please give details of the Credentials/Awards obtained

Training in RANBAXY LAB. for 2 month QC department (instrumentation and micro

PROJECT IN SUPERIOR INDUSTRIES FOR 5 MONTHS IN BEER PLANT (PRODUCTION

ADDITIONAL FACILITIES:
Accommodation Facility:
Will you be requiring Hostel Accommodation?

Yes..

Transport Facility:
Will you be requiring Daily Bus Service from Delhi Sriram Delhi/

.No...

I hereby certify that the above mentioned details are true to the best of my knowledge. If found otherwise,
I am bound by the action taken by the concerned authorities. I do state that I have read the terms and
conditions for admission carefully and abide them.
Signature:

akashagrawal

Date:20-06-2012

* You are required to send DD for Rs. 1050/- towards registrations form and broachers in favour of
SRIRAM BUSINESS SCHOOL/ SRIRAM INSTITUTE OF MENEGEMENT & TECHNOLOGY, payable
at Greater Noida/New Delhi along with the application form.

Received from Mr./Ms. akash agrawal.The application from along with the registration

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fee of Rs. 1050/- vide DD No181828drawn on dated19/6/2012..for admission


Course subject to qualifying the screening test.

For Office Use Only:

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