INDIANINSTITUTEOFTECHNOLOGYBOMBAY

Powai,Mumbai400076

Ph.D.ADMISSIONS(JULY/JANUARY)Year20____

Thisformismeantforforeignstudentsonly

Ph.D.Programmein:

(i) _________________________________________________________________

Paste (do not pin)

passportsizephotograph
inthisspace

(ii) _________________________________________________________________
(fillinthenameoftheDepartment/InterdisciplinaryGroup/Centre/Schoolofyourinterestinorderofpreference).
Areasofyourresearchinterest(inorderofpreference):
(i)__________________________________________________________________
(ii)__________________________________________________________________
2.Nameinfull:(asinqualifyingdegreecertificate)
(TypeorwritelegiblyinEnglishkeeponeblockblankbetweentwowords)

3.(a)Addressofthecandidateforcommunication* (b)Permanentaddressofthecandidate
__________________________________________
_____________________________________________
__________________________________________

_____________________________________________

__________________________________________

_____________________________________________

__________________________________________

_____________________________________________

City______________________________________

City_________________________________________

State______________________Pin____________State__________________Pin___________________
*Itistheresponsibilityofthecandidatetointimatechangeofaddress,ifany,totheDeputy/AssistantRegistrar(Academic),IITBombay.

4.TelephoneNumber:(withISDcode)______________________

MobileNo:_________________________

EmailAddress(s):____________________________________
5.DateofBirth:__________________(DDMMYYYY) 6.Sex(Male/Female):_______________
7.PhysicallyChallenged(Y/N):___________Ifyes,pleasespecify:_______________________
8. Nationality:_________________________

9. Passportdetails:Passportno.:__________________Dateofissue:_____________________

Validupto:__________________Placeofissue:_____________________

10.(a)PerformanceinCompetitiveExamination(suchasGRE,GMAT)
Nameoftheexam:__________________________Year:___________Score:________________
(b)ProficiencyinEnglish(TOEFL/IELTS)
Nameoftheexam:__________________________Year:___________Score:________________
11.DetailsofAcademicRecord(Secondaryonwards)
(MentionifthedegreeisthroughDistanceEducationProgramme)
ExamPassed/
Appeared

Branch

University/Institute

Subject

Month&
Yearof
Passing

Class/
Division

%of
Marks

Grade/CPI/CGPA

12.Research/ProfessionalExperience,Paperspublishedetc.:(Attachaseparatesheetfordetails,if
required)
NameofUniversity/
Institute/Industry

Period

Positionheld/
Natureofduties

Nameof
Supervisor

TitleofDissertation/Topicof
Research/PapersPublished*

*givetitleofpaper,nameofauthor(s),journalname,volume,page(s),yearinaseparatesheet.

13.Employmentdetails:
TotalDuration(inmonths):_________
NameandAddressoftheOrganization

Designation

Period
From

To

(MMYYYY)

(MMYYYY)

14.Declaration:Icertifythattheinformationgivenaboveiscorrect.IamfullyawarethatImustsubmitattested
copiesofmyqualifyingdegreecertificate/finaltranscriptsonorbeforejoiningIITBombay,failingwhich,my
admissionwillstandcancelled.Iamalsoawarethatprovidingincorrectinformationintheapplicationformcan
resultinthecancellationofmyadmissionatanystage.

Place:

Date:

SignatureoftheApplicant

Lastdateofreceiptofcompletedapplicationform:
th
th
Autumnsemester(15Januaryofeveryyear)&Springsemester(15

Julyofeveryyear)