INDIAN INSTITUTE OF MANAGEMENT SHILLONG
FACULTY DEVELOPMENT PROGRAM – 2019
MAY 13th to JUNE 1st, 2019APPLICATION FORM
LAST DATE FOR RECEIVING APPLICATION FORM: APRIL 23
rd, 2019
A. PERSONAL INFORMATION
FULL NAME FIRST MIDDLE SURNAME
DATE OF BIRTH DD MM YYYY GENDER M F
EMAIL PRIMARY EMAIL
SECONDARY EMAIL
PHONE
(WITH STD CODE)
OFFICE LANDLINE RESIDENCE LANDLINE
PRIMARY MOBILE SECONDARY MOBILE
PRESENT ADDRESS
ADDRESS
CITY PIN CODE STATE
PERMANENT ADDRESS
ADDRESS
CITY PIN CODE STATE
EMERGENCY CONTACT
NAME RELATIONSHIP
COMPLETE ADDRESS WITH PIN CODE
MOBILE PHONE
B. EDUCATIONAL AND PROFESSIONAL INFORMATION NAME OF THE DEGREE PERIOD
INSTITUTION /UNIVERSITY % MARKS / CGPA
MAJOR SUBJECTS
FROM TO
GRADUATION
POST-GRADUATION
M. PHIL./PhD
OTHER
PROFESSIONAL EXPERIENCE:
TOTAL DURATION OF TEACHING EXPERIENCE YEARS MONTHS
TOTAL DURATION OF RESEARCH EXPERIENCE YEARS MONTHS
ANY OTHER EXPERIENCE YEARS MONTHS
TOTAL EXPERIENCE YEARS MONTHS
PASTE A RECENT PASSPORT SIZE
PHOTO HERE.
C. PROGRAM AND FEE
a) Three Weeks Program (May 13
thto June 1
st, 2019): ₹ 60,000 + 18% GST b) Two Weeks Program (May 13
thto May 24
th, 2019): ₹ 40,000 + 18% GST c) One Week (Specialization) Program (May 27
thto June 1
st, 2019): ₹ 30,000 + 18% GST
The two week program is the first phase, while the one week program is the last phase of the three weeks programme. The applicant can choose (a) or (b) or (c) from above by placing a tick mark against the concerned option.
In case a participant chooses 3 weeks program and her/his choice of specialisation (one week program) does not run due to limited number of applications, s/he would be considered for 2weeks program. The differential excess fee would be returned.
D. PAYMENT DETAILS
Mode of Payment NEFT/DIRECT CREDIT/DD
UTR No./Transfer ID/ DD No.: Transfer Date/DD Date:
Remitter Bank Name/DD Issuing Bank Name With Branch:
Amount:
*DD to be drawn in favour of “RGIIM SHILLONG”, State Bank of India, Laitumkhrah Branch, payable at Shillong.
If paid by DD, the DD along with the filled in form needs to reach Dean (Academics), Indian Institute of Management, Mayurbhanj Complex, Nongthymmai, Shillong: 793014, Meghalaya on or before April 23rd, 2019.
DETAILS OF SPONSORING INSTITUTION (In case of full or partial sponsorship) Self-sponsored or sponsored by any
Institute/organisation
Name and Address of Sponsoring Institution
Name and Designation of Sponsoring Authority
Signature and Official seal of Sponsoring Authority
Please attach your payment remittance slip/DD only. Do NOT attach any other Supporting documents.
I, ______________________________________, hereby declare and certify that:
1. All the information provided above is true to the best of my knowledge and I am liable to produce proof of such information on demand.
2. I have read and understood the program brochure on the Institute website. I agree to abide by the program and Institute rules.
3. I am medically fit to take part in this residential program.
DATE: PLACE: SIGNATURE:
Note: In case of payment of fee done by NEFT/direct deposit in Institute’s Bank A/c, the duly filled in application form needs to be submitted via email only ([email protected]) along with scanned copy of remittance slip.
