INSTITUTE OF PETROLEUM MANAGEMENT
PETROLEUM MANAGEMENT
APTITUDE TEST( PMAT) 2006
TEST DATE: -- November 2006
ONLINE APPLICATION FORM
Personal Details
Read important instructions carefully before filling form.
Salutation
Mr.
Ms.
First Name
*
Middle Name
Last Name
*
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Age as on September 30,2006
Years
Months
Gender
*
[Select One]
Male
Female
Father's/Mother's Name
Nationality
Address for Correspondence
House No.Street No.
Area/Locality
City
[Select One]
Agartala
Agra
Ahmedabad
Aizwal
Aligarh
Allahabad
Amritsar
Aurangabad
Bangalore
Baroda
Bhopal
Bhubaneshwar
Bokaro
Chandigarh
Chennai
Cochin
Coimbatore
Cuttack
Dehradun
Delhi
Dimapur
Durgapur
Faridabad
Gandhinagar
Ghaziabad
Goa
Gurgaon
Guwahati
Gwalior
Hyderabad
Imphal
Indore
Jabalpur
Jaipur
Jammu
Jamnagar
Jamshedpur
Jodhpur
Jullundhar
Kanpur
Kolhapur
Kolkata
Lucknow
Ludhiana
Madurai
Mangalore
Margaon
Mumbai
Mysore
Nagpur
Nasik
NOIDA
Patna
Panjim
Pondicherry
Pune
Raipur
Ranchi
Rourkela
Rajkot
Salem
Secunderabad
Shillong
Siliguri
Surat
Thane
Thiruvananthapuram
Tiruchirapalli
Udaipur
Varanasi
Vellore
Vijaywada
Vishakapatnam
Other
If other City,please specify
State
[Select One]
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttarakhand
Uttaranchal
Uttar Pradesh
West Bengal
Other
If other State,please specify
Country
[Select One]
India
United States
United Kingdom
Canada
Singapore
Malaysia
Australia
Saudia Arabia
United Arab Emirates
South Africa
Other
If other Country,please specify
Pincode
In Case of Same Address
Permanent Address
House No./Street No.
Area/Locality
City
[Select One]
Agartala
Agra
Ahmedabad
Aizwal
Aligarh
Allahabad
Amritsar
Aurangabad
Bangalore
Baroda
Bhopal
Bhubaneshwar
Bokaro
Chandigarh
Chennai
Cochin
Coimbatore
Cuttack
Dehradun
Delhi
Dimapur
Durgapur
Faridabad
Gandhinagar
Ghaziabad
Goa
Gurgaon
Guwahati
Gwalior
Hyderabad
Imphal
Indore
Jabalpur
Jaipur
Jammu
Jamnagar
Jamshedpur
Jodhpur
Jullundhar
Kanpur
Kolhapur
Kolkata
Lucknow
Ludhiana
Madurai
Mangalore
Margaon
Mumbai
Mysore
Nagpur
Nasik
NOIDA
Patna
Panjim
Pondicherry
Pune
Raipur
Ranchi
Rourkela
Rajkot
Salem
Secunderabad
Shillong
Siliguri
Surat
Thane
Thiruvananthapuram
Tiruchirapalli
Udaipur
Varanasi
Vellore
Vijaywada
Vishakapatnam
Other
If other City,please specify
State
[Select One]
Andaman and Nicobar Islands
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chattisgarh
Dadra and Nagar Haveli
Daman and Diu
Delhi
Goa
Gujarat
Haryana
Himachal Pradesh
Jammu and Kashmir
Jharkhand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttarakhand
Uttaranchal
Uttar Pradesh
West Bengal
Other
If other State,please specify
Country
[Select One]
India
United States
United Kingdom
Canada
Singapore
Malaysia
Australia
Saudia Arabia
United Arab Emirates
South Africa
Other
If other Country,please specify
Pincode
Email Address
Email :
Alternate Email :
Contact Numbers
Mobile
(For Ex. +919876664554)
Residence
(For Ex.+912234566543)
Office
(For Ex.+912234566543)
Fax
(For Ex.+912234566543)
Academic Background
Examination
University / Board
Degree Awarded
Principle Subjects Undertaken
Year of Passing
Grade / Division
Percentage
SSC
HSC
Graduation
Post Graduation
Any other
Current Employment Status
Employed
Self-employed
Currently not employed
If currently employed, details of the current employment
Current Designation
Name of the Employer
Employed Since
Month
January
February
March
April
May
June
July
August
September
October
November
December
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Total Professional Exposure
Full time
Year
Months
Days
Part time
Year
Months
Days
Prizes, Awards, Honours, Scholarships Received or Other Academic Distinctions:
(Please list those received post school education only)
Prizes, Awards, Honours or
Scholarships Received
Year
Accomplishment
Awarded by
Country/State
Activities And Interests:
Place list in order of importance any extra-curricular activity you are/have been involved with:
Duration
Activity
Role Played
Awards/Recognition
Country/State
PMAT Exam Center Code
[Select One]
Ahmedabad
Baroda
New Delhi
Bangalore
Chennai
Mumbai
Kolkata
Hyderabad
*
Select Bank for depositing payment
[Select One]
ICICI Bank
HDFC Bank
State Bank of Saurasthra
UTI Bank
*
Account Number
Declaration:
I, hereby, declare that all the particulars stated in this application are true to the best of my knowledge and belief. In the event of suppression or distortion of any fact like educational qualification, age, nationality etc. made in my application form, I understand that I will be denied admission and if already admitted, my admission is liable for cancellation. Further if admitted I promise to abide by the rules, regulations and discipline of the institute.I also understand that merely submission of the Online Application Form, obtaining the Acknowledgement Receipts along with the unique Registration Number and Admit Cards by either printing and/or by receiving in my e-mail account does not necessarily entitles me for candidature at GERMI-IPM PMAT. GERMI will process my application only on receipt of Application Fee deposited with one of the selected Banks. I accept that that the GERMI IPM PMAT will be held as per the regulations mentioned in the PMAT Bulletin. Only appearing for the PMAT and being called for Group Discussions & Personal Interviews does not mean that I am necessarily eligible & entitled for admission.
I Accept the Declaration