International Institute of
rojects & Program Management

(a not for profit company)
setting a new benchmark in executive education globally &
pioneering project management certification worldwide


Certificate In Project Management
Application Form

Section 1

1.1 Name
      Prefix:(Mr./Mrs./Ms./Dr.)                                                               First Name

         Initial                                             Last Name                                               Date of Birth

      Name for printing in certificate if different to above:                                                                                

1.2 Home Address (If applying from outside India, kindly indicate your country*)

     City:      State:      Country:*

     Pin/Zip code

1.3 Email Personal:                                                                            Email Work:

1.4 Phone
     Country Code     City Code     Mobile No

     Work Landline:          Extension:

1.5 Number of hours of Project Management Training Undergone:  
      (Minimum of 20 hours of project management
      training is required for certification) (rounded to integer)

1.6 Highest Qualification:         Expereince in Yrs:      

1.7 Designation:

1.8 Your main industry:

1.9 Company Name & address (If applying from outside India, kindly indicate your country*)

     City:      State:      Country:*

     Pin/Zip code

1.10 Photo ID Type          Reference No. 
        (PAN / Aadhar / Driving License / Passport / Company issued Identity)

1.11 Self certified copy of the project management training program of 20 hours minimum.
       (Not required as you have gone through module 1 of Totality of Project Management.)

1.12 Self certified copy of the Graduation certificate or any other higher degrees.

1.13 Special Needs (if any) 
      (For example, related to physical disability)

Section 2                                                           DECLARATION


   S/o, D/o/ W/O hereby declare that:

* I am aware about the CIPM Certification Process & examination format. I will comply with certification process
   requirement & will supply any and all information needed for assessment purpose.

* I am a graduate in  and have got valid degree from university/Institute of

* I have undergone 20 hours of formal training in Project Management in line with the CIPM syllabus from (Name of

* Scope of the Certificate In Project Management certification is known and fully clear to me along within the certification
   process, certification assessment methodology and certification prerequisites.

* I will maintain full confidentiality of the certification examination. I will not copy, share, distribute or use any unethical
   means in answering the examination paper.

* I will not copy the examination paper questions nor will I disclose the exam paper contents to any person whatsoever.

* I will work towards the best interests of my organisation, society at large, public safety and the environment.

* I will be fair in all my dealings and work with out any prejudice or bias with all stakeholders, customers partners
   irrespecve of their status, gender, age, caste, religion.

* I will discharge my dues ethically with utmost integrity and keep stakeholders informed as requires in performing my

* As a professional working directly or indirectly in projects, I agree to honour and abide by the Code of Ethics and
   Professional Conduct of Internaonal Instute of Projects and Program Management as given to me. It is also available
   on their website https://www.i2p2m.com/page/cipm_code_of_ethics.

* On earning the CIPM credential, I will comply to the Code of Ethics & Professional Conduct and if there is any non
   compliance to this Declaration, I will inform i2P2M without delay.

* In case my certification is suspended or withdrawn, I will not use certification credentials. i2P2M will have rights to
   publically display my changed status on i2P2M website.

   Date:                                       Signature: