INDIAN INSTITUTE OF PHARMACEUTICAL MARKETING

Sapt-Rishi, 5/28, Vikas Nagar, Lucknow-226022

0522-2766456, 9415101772

iipmindia@rediffmail.com

APPLICATION FORM FOR ONLINE ADMISSION

Please complete clearly in BLOCK LETTERS and mark in appropriate boxes. (Bold fields have to be completed)

Course Chosen (Use Ctrl key to select more than one option)
Title		Mr Mrs Ms
Name
Address For Communication
Pincode
Phone
E-mail: (if available)
Date of Birth (as given in high school certificate)
Educational Qualification (1)
Educational Qualification (2)
Educational Qualification (3)
Whether Employed		Yes No
Mode of Exam Postal		Postal Lucknow Centre
State whether NRI / foreign Student		Yes No
Do you want Study Material to be sent by Registered Post (if yes then add required postal Charges in fee)		Yes No
Do you want to do the course in FAST TRACK SYSTEM (if yes then add required Charges in fee)		Yes No
Mode of payment
Payment Details	Cash	Rs
	Draft	No.	Date
		Bank
		Amount

I have read the conditions applicable to the courses as described in the prospectus along with terms and conditions on application form and agree to abide by the same.