Details for Course Applied & Center (Candidate can apply on more than one course )
1	Name of Post Graduate Diploma Course: * (If Candidate want to apply for regional course Like(Odia/ Urdu/ Marathi/ Malayalam) then it will choose from first option )	---Select--- Advertising and Public Relations Journalism(English) Journalism(Hindi) Radio & TV Journalism Odia Journalism Urdu Journalism Marathi Journalism Malayalam Journalism      ---Select--- Advertising and Public Relations Journalism(English) Journalism(Hindi) Radio & TV Journalism      ---Select--- Advertising and Public Relations Journalism(English) Journalism(Hindi) Radio & TV Journalism      ---Select--- Advertising and Public Relations Journalism(English) Journalism(Hindi) Radio & TV Journalism
2	Choice Examination Center : *	------Select------- AHMEDABAD AIZWAL BANGALORE BHOPAL CHENNAI GUWAHATI HYDERABAD JAMMU KOLKATTA LUCKNOW MUMBAI NEW DELHI PATNA RAIPUR RANCHI SRI NAGAR DEHRADUN DHENKANAL AMRAWATI KOTTAYAM      ------Select------- AHMEDABAD AIZWAL BANGALORE BHOPAL CHENNAI GUWAHATI HYDERABAD JAMMU KOLKATTA LUCKNOW MUMBAI NEW DELHI PATNA RAIPUR RANCHI SRI NAGAR DEHRADUN DHENKANAL AMRAWATI KOTTAYAM
3	Medium of Exam : * If candidate apply for more than one course with (Odiya, Urdu, Marati & Malayalam) than candidate will choose second Medium of Exam from option.	------Select------- Hindi English Odia Urdu Marathi Malayalam      ------Select------- Hindi English
4	Indicate preference of IIMC center for pursuing course in Journalism (English) : *	Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi Select Aizawl Amrawati Dhenkanal Jammu Kottayam New Delhi
Applicant Details
5	Name Of Applicant: *
6	Date of Birth: *	DD 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 MM 1 2 3 4 5 6 7 8 9 10 11 12 YYYY 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 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
7	Gender *	-----------Select------------ Male Female
8	Nationality-Indian*	-----------Select------------ INDIAN NRI
9	Category: *	-----------Select------------ General Scheduled Caste Scheduled Tribe Other Backward Class
10	Physical Handicapped: *	-----------Select------------ Yes No
11	Upload Photograph of Applicant (Allowed filed size: 10-20KB, Allowed File Type: jpeg/jpg) : *
12	Upload Signature of Applicant (Allowed filed size: 10-20KB, Allowed File Type: jpeg/jpg) : *
13	Write your Name & complate mailing Address : *	Name Address District State Pin Code
14	Mobile Number (Not start with 0) *
15	E-mail id :  *
Applicant Guardian Details
16	Father's / Guardian's Name : *
16-A	Father's / Guardian's Mobile No (Not start with 0): *
17	Mother's / Guardian's Name : *
17-A	Mother's / Guardian's Mobile No (Not start with 0): : *
18	Profession of Father / Guardian : *
19	Profession of Mother / Guardian : *
20	Annual Family Income (In Rs.) : (Please do not use ./,().etc.) *
Education Qualification Details
21	Graduation: *	-----------Select------------ Passed Appearing Result Awaited
22	Qualification Board/University Passing year Percentage (e.g. 65.01) Name of School/College Name of the degree (BA/BCOM/etc) 10th * 12th * Graduation * Post Graduate
Work Experience Details
23	Designation Name :
24	Name of Institution :
25	Duties performed :
Declarations
I do hereby declare that all the statements made in this application are true, complete and correct to the best of my knowledge and belief. in the event of any statement/information being found false/incorrect/incomplete or ineligibility being found before recruitment or after appointment, my candidature/appointment will stand automatically cancelled.