Scribd
Upload
174 views1 page

Sales Agent Distance Learning Application

This document is an application form for admission to distance learning programs offered by the IIRM Institute of Insurance and Risk Management. The programs offered are the IPGDI (Life), IPGDI (General), and IPGDRM (Risk Management). The application requests personal details of the applicant such as name, date of birth, addresses, educational and professional qualifications, employment history, and how they heard about the IIRM. The applicant must declare that the information provided is true and correct, and that they understand the requirements to pass all subjects with 55% marks, appear for re-sit exams if needed, and complete the course within 3 years.

Uploaded by

Najhma Shaik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
174 views1 page

Sales Agent Distance Learning Application

This document is an application form for admission to distance learning programs offered by the IIRM Institute of Insurance and Risk Management. The programs offered are the IPGDI (Life), IPGDI (General), and IPGDRM (Risk Management). The application requests personal details of the applicant such as name, date of birth, addresses, educational and professional qualifications, employment history, and how they heard about the IIRM. The applicant must declare that the information provided is true and correct, and that they understand the requirements to pass all subjects with 55% marks, appear for re-sit exams if needed, and complete the course within 3 years.

Uploaded by

Najhma Shaik
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

IIRM INSTITUTE OF INSURANCE AND RISK MANAGEMENT

(Jointly set up by IRDAI and Government of Telangana)


Plot No.38/39, Financial District, APSFC Building, Ground Floor, Nanakramguda, Gachibowli, Hyderabad – 500 032.
[Link]: +91 40 23000005, Fax: +91 40 23000254 Email: dlemail@[Link], Website: [Link]

APPLICATION FOR ADMISSION TO DISTANCE LEARNING PROGRAMMES

Course applied for IPGDI (Life) IPGDI (General) IPGDRM (Risk Management)
Affix Photo
Application form No. to be filled by IIRM office

Particulars of payment for Rs.500/- towards Registration Fee.


Payment Mode: Date:

Name (as shown in SSC certificate): Mr./Ms.: _________________________________________

Father’s Name: ____________________________ Spouse Name: _________________________


Date of Birth : ____________________________ Age : _________________________

Office Address : __________________________________________________________________


______________________________________________________________________________________________

Phone : ____________________________ Mobile : ________________________________

Residential Address : ______________________________________________________________


___________________________________________________________________________________________________________________________

Phone : ____________________________ Mobile : _______________________________

Address for Communication : _______________________________________________________


_______________________________________________________
Phone : ____________________________ Email : _______________________________

Educational and Professional Qualifications acquired (copies to be enclosed)


Qualification Year & Month of University / Institution Aggregate
passing Percentage

Particulars of Employment:
Designation and nature of job Organization and address From To Number of
Yrs. & Mths

How did you come to know about IIRM______________________________________________

DECLARATION OF THE APPLICANT


1. I hereby declare that all information furnished by me are true, complete and correct to the best of my knowledge and belief.
2. I am aware that I should pass all the subjects with 55% of marks to become eligible for award of IPG Diploma of the Institute and for CII
accreditation and that I have to appear re-sit exams, if necessary, to fulfill this condition.
3. I am also aware that I have to complete the course in all respects within three years counting from the year of enrolment.

Date: Place: Signature of the Applicant:

You might also like