JAGRAN INSTITUTE OF MANAGEMENT

620, W Block Saket Nagar - Kanpur - 208014

(Approved by AICTE, Ministry of HRD Govt. of India and Affiliated to UPTU, Lucknow)

Ph.No: 0512- 2601126, 9336332150

APPLICATION FORM

Affix Photograph

(For Office use only)

STUDENT'S DETAILS

Full Name (Block Letters)

Date of Birth

m md d m y y yy

GENDER :

Male

Female

Student's Mobile No.

m

Occupation : ____________________________

CORRESPONDENCE ADDRESS

PERMANENT ADDRESS

Father’s Name

Student's Email

ACADEMIC QUALIFICATION

Name of the School / College Board / University

Year of Passing

Percentage of Marks

High School

Intermediate

m

GraduationBA/B.Sc./ B.Com./BBA/BCA/Others

Details of the DEMAND DRAFT/ CASH/ ONLINE Details

m md d m y y yyDated

Amount

Bank & Branch Name

I declare that all the particulars provided by me above are true SIGNATURE

DECLARATION

Amount in words

Amount

Amount in words

I declare that all the particulars provided by me above are true

DECLARATION

Signature Date

Application Form No. : JIM/KNP/STC/2018/01

Occupation: _____________________________

Mother’s Name

Father's Mobile No.

Father's Email

For Admission to Short Term Course (STC)

Advanced Excel, Tally, Cloud Computing , Android