Form No.

Mudra Institute of Communications, Ahmedabad

Shela, Ahmedabad - 380 058, Gujarat, India
Rs.1500 Tel. : +91 2717 237946 to 51 and 308250
(Non-Refundable)
Fax : +91 2717 308349
Website : www.mica-india.net
Application Form Email: pgpcmx@mica.ac.in

Executive Post Graduate Diploma in Management (Communications) PGPCMX

Batch: 2010-11

Instructions
1 This form is an integral part of the admission process. Please provide correct information. Admission granted on the basis of
incorrect information will be ipso facto null and void.
2 Completed application forms should reach the Chairperson (PGPCMX) MICA on or before 6th March, 2010.
3 Forms downloaded from the website shall be alloted a unique form number on receipt by the admissions office, MICA. This number
shall be intimated to the candidate by email as an acknowledgement.
4 Candidates short listed will be called for the MICA Admissions Test (MICAT), a Group Exercise (GE) and a Personal Interview (PI) on
21st March, 2010.
5 Please mention your MICA form number in all your correspondence with us. Any change in your address should be intimated to us
immediately.
6 In all matters regarding admission to the programme, the decision of the Institute will be final and binding. No corresponden ce from
the applicant with respect to his/her non-selection will be entertained.
7 The Institute reserves the right to re-schedule/change/cancel venue for MICAT/GE/PI.

A Personal Details (BLOCK LETTERS)

Name
Last Name First Name Middle Name

Address
(for correspondence)

City Pin

Telephone Mobile Fax

Email

Email

Gender Male Female Date of Birth (D/M/Y) Age

Nationality Marital Status

Name of Father / Mother / Guardian Affix a recent passport size

photograph and sign across it
(not more than three
Occupation of Father / Mother / Guardian months old).

Academic Qualification of Father / Mother / Guardian

B Education

Name of Year of Marks/Grade Major Subjects/ School/College/Academic Board/

Examination Passing (%) Discipline University

Class 10

Class 12

Bachelor's Degree

(mention your degree in

space provided above)

Master's Degree

(mention your degree in

space provided above)

Other Examination

(mention your degree in

space provided above)

C List no more than three training programmes / courses (other than your academic courses) that you have
completed and consider important.

Sr. No. Programme/Course Duration/ Institution Benefits/Skills Derived

Dates

3
D List no more than three significant achievements during your professional career.

Sr. No. Achievements Year What personal traits/qualities do you believe

were instrumental in this achievement ?

E Work Experience (only full time and more than six months in the same job). Please attach detailed resume.

Sr. No. Designation and Nature of Work Name of Organization Period Total Pay (Rs./Month)
Months

F Personal Statement

(a) Describe briefly how you see yourself as a person.

(b) List three strong likes/dislikes (in order of preference).

Likes Dislikes

1. 1.

2. 2.

3. 3.
(c) What are your career goals?

(d) Please attach a statement of purpose explaining your motivation for joining this programme? (not more than 250 words)

G How did you come to know about MICA ? (Please tick wherever applicable)

Advertisement Posters/Notice Board Posters/Notice Board at

at College Coaching Classes

Friends/Parents/Relatives MICA Alumni Industry Professionals

MICA Website Others ( Please Specify )

H In which publication did you read the MICA admissions advertisement ? (Please tick wherever applicable)

Business Standard Hindustan Times The Hindu

Economic Times Online Forums/Blogs Agency FAQ’s

Others (Please Specify_______________________)

I Financial Status of Parents (individually or combined)/Guardian

Annual Income Less than Rs. 3 lac Between Rs. 3 lac and Rs. 5 lac

Between Rs. 5 lac and Rs. 7 lac Above Rs. 7 lac

J Declaration
I have carefully read the prospectus and agree to abide by the decisions of the Institute regarding my selection to the programme.
I certify that the information furnished in this application form is correct to the best of my knowledge and belief.

Place Date Signature of the Applicant

DO NOT ATTACH ACADEMIC CERTIFICATES AND MARK SHEETS OR THEIR TRUE COPIES TO THIS FORM.
PLEASE NOTE THAT INCOMPLETE FORMS WILL BE REJECTED.