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Business School

INDIAN INSTITUTE OF COMMERCE AND TRADE, LUCKNOW

Department of Distance and Open Learning
APPLICATION FORM FOR ADMISSION
(Please fill clearly in block letters and mark tick in appropriate box)

1. a) Programme Applied For .................................................................

b) Give Specialization if any:.........................................................................
2. Programme Code : [ ][ ][ ][ ][ ][ ][ ][ ] Affix Self
3. Name (In English)............................................................................... Attested Recent
Name (In Hindi)................................................................................. Photograph of
4. Father's Name.................................................................................. Candidate
5. Date of Birth: Day [ ][ ] Month [ ][ ] Year [ ][ ][ ][ ]
6. Sex: Male [ ] Female [ ] 7. Marital Status: M. [ ] UM. [ ]
8. Nationality: ........................... 9. State if: NRI [ ] Foreign Student [ ]
10. Present Mailing Address: ................................................................................................
(in capital letters) .............................................................................................................
City ..........................District ............................State ......................................................
E-mail address (if any):.....................................................................................................
Pin Code :………………………… Telephone:……………………………..
11. Permanent Home Address: .............................................................................................
(in capital letters) .............................................................................................................
City ..........................District ............................State......................................................
Pin Code:………………………… Telephone :……………………………..
12. Educational Data :
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 Organization / Company ….. [ ][ ][ ]
(c) Working Experience (attach separate 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 [ ] EFT/Net Transfer [ ]
(b) Mode of Payment of fee: Lumpsum [ ]. Instalment: Scheme I [ ] Scheme II [ ]
Name of Bank DD /Cheque / EFT No. Date of Issue 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 [ ]
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 [ ]
c) If yes, Have you enclosed required undertaking. Yes [ ] No [ ]
19. You came to know about this course through
(a) News Paper [ ] (b) IICT Student [ ] (c) Internet [ ] (d) Any other means [ ]
20. Choice of optional papers for MBA, MBA (Dual Spl.) and EMBA (Give Subject Code Only):
Semester I Semester II Semester III Semester IV
a) MBA CT ....... CT....... CT....... CT- .......
b) MBA CT ....... CT....... Major: - CT .......,CT .......,CT ....... CT-.......
(Dual Spl.) Minor: - CT .......,CT .......
c) EMBA (IInd Semester): CT .............,CT ..............,CT ..............
Instructions
Completed application form should be sent to THE DIRECTOR, IICT, 5/28, VIKAS NAGAR, LUCKNOW-226022, by Registered
Post/Courier/Speed Post. The application form should be accompanied with the required fee (crossed Demand Draft drawn in
favour of IICT payable at Lucknow or Counter foil of Electronic Fund Transfer Receipt).
Declaration
I have carefully read the Academic and Administrative Rules and Regulations of IICT 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. A list of enclosures is attached with this application form.

Date.................. Place................. Signature of Student

For Office Use Only
Application Received on............................................ Enrolment No.................................
Admitted on.............................................................. Programme.....................................
Receipt No..................... Date................... Rupees....................................................................
Mode of Payment......................................................
Date of next Fee Instalment if any............................... Dy. Director (Adm.)
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Procedure/Instruction for Admission Form

Students need not send/submit their original certificates. The following self attested documents are
to be enclosed along with the filled-in application

The following documents are to be attached with the completed Application Form.

• Two passport size photographs

• Photocopy of the Degree/Diploma or the final year mark Sheet.
• Photocopy of the High School Certificate for the verification of the date of birth, Student's and
Father's name.
• Demand Draft of fee / cash deposit slip of bank / transaction detail in case of electronic transfer.
• If sending Demand Draft then its in favour of Indian Institutes of Commerce and Trade payable at
Lucknow

The filled-in application along with the required documents should be sent by Registered Post /
Courier to :-

The Director,
Indian Institute of Commerce and Trade
(Department of Distance Education),
"SAPT RISHI", 5/28, Vikas Nagar ,
Lucknow - 226022 (India) .
Phone: +91-522-4004049, +91-522-6545285, 9415101772