International Student Exchange (2014-15) - Application Form

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Indian In#titute o $anagement Indore
Po#t %raduate Programme
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(0o 9e #u9mitted to the P%P 2ice 9: $onda:; Fe9 10; 2014 late#t 9: <*00 P$)
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Experience a9road*
<( 3anguage* Plea#e indicate :ou proicienc: o language# AnoBn on a #cale o 1 to < a# under*
1 - Elementar: AnoBledge
2 - $oderate luenc:
< - Fluent
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International Student Exchange (2014-15) - Application Fonn
4( Educational 5etail#*
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International Student Exchange (2014 -15) - Application Form
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-( )hat do :ou AnoB a9out the exchange partner in#titution#).
P( ,6Lhat eed9acA ha@e :ou recei@ed rom participant# Bho are currentl: #tud:ing in the exchange
in#titution(#) L ha@e completed a term in the exchange in#titute(#).
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10( QRhat credi'd do :ou plan to &taAe Bhile on exchange. r
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lntcrnational Student Exchange (20l4-15) - Application Form
11( In a9out a hundred Bord#; explain Bh: :ou Bant to #tud: a9road and hoB :ou hope thi# Exchange
Programme Bill impact :our academic; proe##ional and per#onal de@elopment(
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12( $edical itne##* a#e gi@e detail# o an: exi#ting ph:#ical di#a9ilit: or chronic illne##; including
mental illne##; Bhich could aect :our #ta: and #tudie# i #elected or the exchange progr-amme(
0hi# inormation will 9e Aept conidential(
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1<( Financial Inormation*
8oB do :ou intend to inance :our participation in the exchange programme*
' 0 3oan 0 2ther (plea#e #tate) (
4ndertaAing
I undertaAe that all the inormation #tated a9o@e i( true to the 9e#t o m: AnoBledge(
I here9: declare that 1 am intere#ted in thi# programme and if #elected I Bill go a# Exchange Student to the
W-School I am #elected or( In ca#e 1 am not a9le to go or exchange; I Bill he lia9le to pa: the applica9le
penalt: to In#titute( I Bill 9e lia9le to 9ear an: co#t incurred due to #uch cancellation and an: due# to 9e
#ettled Bith the exchange uni@er#it: allotted to me(
I al#o declare that I Bill a9ide 9: all rule# and regulation o parent and ho#t in#titution#; a# applica9le rom
time to time(
5ace* ((( 21/03./.2QJ.Y .....:
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DECLARATION BY PARENT / GAURDIAN
, rn ,2-./ ~~ k:tM"vl OJ] A 'iAJ1 B+ parent / guardian of
A A J 3;;'w j agoing on the Exchange Programme during September -
DecembeC iAo r rm TV) d
6.n e hereby affirm that am in complete
knowledge of his decision to go on the Exchange Programme. grant him my consent for. the
same. also understand that A g~, ~ 7I+1 B(Ci will be solely responsible
for himself while on the Exchange prograr~: .
Date: 2:7 I 0 '$ J 2 Q
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Signature