Indian Institute of Management Sambalpur: June 2020. (Mention: Application For Application Form

Indian Institute of Management Sambalpur
Jyoti Vihar, Burla, Sambalpur, Odisha - 768019

__________________________________________________________________
Executive Ph.D. Programme 2020 Admission
Instructions and Enclosures for filling the Application Form
(ONLY TYPE WRITTEN)
Please download the application and fill your details (only type written). You are required to
send the completed application form (duly signed) along with all the relevant documents through
email to [email protected] on or before 12th June 2020. (Mention: Application for
Executive PhD 2020 in subject line of mail). Following documents are to be mailed along with
Application Form.
a. Two mandatory recommendation letters (to be mailed by Referee)

b. Copy of Govt. issued photo identity proof
c. Copies of SSC, HSC Mark sheets and certificates
d. Copy of Master’s/Bachelor’s mark sheets and certificates
e. Copy of Professional degree marks sheets and certificates
f. Copy of Test Score Card (CAT/GRE/GATE/GMAT/JRF (UGC/CSIR))
g. NEFT/RTGS transaction slip of Application Fee
h. Copy of Work Experience certificate (NOC is required at the time of Admission)
i. Copy of Caste and disability Certificate, if applicable
i. Please note NC-OBC is valid for one year from the date of issue
ii. PwD certificate must be issued by a Govt. Hospital
Provide your latest photograph in the application which is mandatory. Any

application submitted without photograph will be rejected.
Page 1 of 10
Indian Institute of Management Sambalpur
Jyoti Vihar, Burla, Sambalpur, Odisha - 768019
__________________________________________________________________
Executive Ph.D. 2020 Admission
Application Form
Fill in the form carefully and completely and send through email to PhD Office
([email protected]) along with other required documents on or before 12th June
2020.
INCOMPLETE APPLICATIONS WILL NOTE BE ACCEPTED
Application Fee Details
Payment Date Bank and Branch UTR/Transaction No Amount
 Are you opting for IIM Sambalpur Aptitude Test (IIMSAT): Yes:______No______
 Are you a PGP Alumni of any IIM of regular course: Yes:______No______
 Are you a regular PGP from top 50 institutions of NIRF Ranking (2018/2019) with CGPA
6.0: Yes: ________ No________
1. AREA OF SPECIALIZATION:
First Preference: ______________________________ Recent Photo (Self

Attested)
Second Preference: ____________________________
2. PERSONAL DETAILS:
Full Name (Capital
Letters)
Current/Correspondence
Address with Pin
Page 2 of 10
Permanent Address with
Pin
Email ID (Valid)
Alternate Email ID
Contact Number
Alternate Contact
Number
Date of Birth
(dd/mm/yyyy)
Gender
Blood Group
Citizenship
Category
Personal with Disability
Marital Status
Name of
Spouse/Parent/Guardian
Govt. ID Number
Annual Family Income
Father’s Highest
qualification
Mother’s Highest
qualification
Page 3 of 10
How did you come to know about this program ____________
Have you been associated with us earlier___________________
If yes, please furnish the details_________________________________________________
3. EDUCATIONAL QUALIFICATION (in reverse chronological order)

S.No Name of University/Institute Main Year of % of Class/Div Distinction
Exam/Degree Subject Passing Marks (if any)
4. WORK EXPERIENCES (in reverse chronological order)

S.No Organization Designation From To Gross Reason
Annual for
Salary leaving
Page 4 of 10
Total Work Experience Years______________Months________________ as 12th June 2020.
International Experience, if
any___________________________________________________
5. PROFESSIONAL REFERENCES: Two persons who know you
academically/professionally.
Name Organization Designation In which Contact No Email
capacity
6. PUBLICATIONS, if any:
Page 5 of 10
7. TEST SCORE DETAILS:
Name of test, if any Details (Reg No. Year, Total Score/Percentile,

All India Rank, Discipline, etc)
8. ADDITIONAL INFORMATION (Extra Curricular Activities)
9. AWARDS AND DISTINCTIONS
Page 6 of 10
10. Any other information you wish to state which may be relevant for shortlisting your
application.
11. Research Proposal for First Area Preference – 1 (About 500 Words)Write about why you
want to pursue EFPM from IIM Sambalpur, what do you intend to do, why you think you
have the necessary prerequisites and also how your plans align with the institute? Mention
about the research that you wish to pursue at the Institute.
Page 7 of 10
12. Research Proposal for Second Area Preference – 2 (About 500 Words) Write about why
you want to pursueEFPM from IIM Sambalpur, what do you intend to do, why you think you
have the necessary prerequisites and also how your plans align with the institute? Mention
about the research that you wish to pursue at the Institute.
Page 8 of 10
13. LIST OF DOCUMENTS ATTACHED WITH THIS APPLICATION: (Please tick)
a. Two mandatory recommendation letters (to be mailed by Referee)

b. Copy of Govt. issued photo identity proof
c. Copies of SSC, HSC Mark sheets and certificates
d. Copy of Master’s/Bachelor’s mark sheets and certificates
e. Copy of Professional degree marks sheets and certificates
f. Copy of Test Score Card (CAT/GRE/GATE/GMAT/JRF (UGC/CSIR))
g. NEFT/RTGS transaction slip of Application Fee
h. Copy of Work Experience certificate (NOC is required at the time of Admission)
i. Copy of Caste and disability Certificate, if applicable
i. Please note NC-OBC is valid for one year from the date of issue
ii. PwD certificate must be issued by a Govt. Hospital
Page 9 of 10
14. DECLARATION
I have carefully read the instructions and agree to abide by decisions of IIM Sambalpur
authorities regarding my selection to the Executive Ph.D. Programme 2020. I certify that the
particulars given by me in this form are true to the best of my knowledge. I know that at any
time if the information furnished by me is found incorrect, my candidature will be cancelled
immediately.
I declare that currently there is no criminal offence registered against me in any court of law
and have never been convicted for such offence in the past.
Place:
Date:
______________________________
Signature of Applicant
Page 10 of 10

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Indian Institute of Management Sambalpur

Jyoti Vihar, Burla, Sambalpur, Odisha - 768019

a. Two mandatory recommendation letters (to be mailed by Referee)

Provide your latest photograph in the application which is mandatory. Any

First Preference: ______________________________ Recent Photo (Self

Personal with Disability

Annual Family Income

Have you been associated with us earlier___________________

If yes, please furnish the details_________________________________________________

3. EDUCATIONAL QUALIFICATION (in reverse chronological order)

4. WORK EXPERIENCES (in reverse chronological order)

Name of test, if any Details (Reg No. Year, Total Score/Percentile,

8. ADDITIONAL INFORMATION (Extra Curricular Activities)

9. AWARDS AND DISTINCTIONS

a. Two mandatory recommendation letters (to be mailed by Referee)

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