Business School
INDIAN INSTITUTE OF PHARMACEUTICAL MARKETING, LUCKNOW
Department of Distance and Open Learning
APPLICATION FORM FOR ADMISSION
(Please fill clearly in block letters and mark  tick in appropriate box)
 
Personal Detail:
1. a)Programme Applied For
2. Programme Code :
3. Name
4. Father's Name
5. Date of Birth  Pick a date
6. Sex Male Female 7. Marital Status M.     UM.
8. Nationality 9. State if NRI Foreign Student
10. Present Mailing Address
     City District State
     E-mail address Pin Code Telephone
11. Permanent Home Address
     City District State
     Pin Code Tele Phone    
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12. Give Applicable Educational Data as per Course Eligibility :
Sr.No. Examination Passed Year of Passing Board/Institute/University % of Marks
1.
2.
3.
4.
5.
13. a)Whether Employed : Yes No
b) If Employed give Name of Employer
c) Working Experience (attach seprate sheet if required) :
Sr.No. Name of Organisation From To Post Held Remarks
1.
2.
14. Category Code for Fee Concession if applicable:
15. a) Payment Details : Cash Draft/ChequeMoney Money Fund Transfer
b) Mode of Payment of fee: Get fees details click here
Lumpsum Instalment: Scheme I Scheme II 
Name of Bank DD /Cheque/Cash / Money Transfer I.D. No.         Date of Issue/Deposit Amount
16. Have you enclosed : a) Registration Fee Yes No
  b) Postal Charges Yes No
  c) Examination Fee       Yes No
17. Option for Examination:   a) At examination Centre Lucknow
  b) Assignment Based Examination (Postal)
  c) On Line Examination
18. a)Have you opted for fast track system to complete the course. Yes No
b) If yes, Have you enclosed fee for Fast Track System. Yes No
19. You came to know about this course through:
(a) News Paper (b) IIPM Student (c) Internet (d) Any other means
20. Choice of optional papers for MBA, MBA (Dual Spl.) and EMBA (Give Subject Code Only): Get Subject Code click here
  Semester I Semester II Semester III Semester IV
a) MBA PM PM PM PM
b) MBA (Dual Spl.) PM PM
Major PM PM PM
Minor PM PM  
PM
c) EMBA (IInd Semester): PM PM PM
Enclose Self Attested copies of following Requared documents:
High School Certificate(10) :    Intermediate Certificate(10+2):    
Graduation Certificate :            Exprience Certificate if required:
Fee Concession Certificate :     Employment cerificate :             
Diploma Certificate :                 Other :                                    
Fee Deposit Detail:                  
Instructions
Completed application form should be submitted to The Director, IIPM. On The application form mention the details of the required fee (crossed Demand Draft drawn in favour of Indian Institute of Pharmaceutical Marketing payable at Lucknow or Counter foil of Electronic Fund Transfer Receipt).
Declaration
I have carefully read the Academic and Administrative Rules and Regulations of IIPM for Correspondence Programmes as given in the information brochure and agree to abide by the same. I hereby declare that if I am enrolled in the programme applied, I agree to pay balance of fee instalments on specified dates. I further declare that the information provided by me in the application is true to the best of my knowledge and belief.
Date  Pick a date Place