INDIAN INSTITUTE OF TECHNOLOGY  BOMBAYPowai, Mumbai – 400 076

Ph.D. ADMISSIONS (JULY/JANUARY) Year 20_ _    ­ _ _

   .

This form is meant for foreign students only

                                                                                               Ph.D. Programme in :

(i) _________________________________________________________________ 

(ii) _________________________________________________________________   

 (fill in the name of the Department / Interdisciplinary Group / Centre / School  of your interest in order of preference).

Areas of your research interest (in order of preference) :

 (i) __________________________________________________________________

 (ii) __________________________________________________________________

2. Name in full: (as in qualifying degree certificate)(Type or write legibly in English ­ keep one block blank between two words)

3. (a) Address of the candidate for communication*  (b) Permanent address of the candidate  __________________________________________ _____________________________________________

__________________________________________ _____________________________________________

__________________________________________ _____________________________________________

__________________________________________    _____________________________________________

City ______________________________________ City _________________________________________

State ______________________Pin ____________             State __________________Pin ___________________

* It is the responsibility of the candidate to intimate change of address, if any, to the Deputy /  Assistant Registrar (Academic), IIT Bombay.

4. Telephone Number: (with ISD code) ______________________ Mobile No : _________________________  

    E­mail Address(s) : ____________________________________

5. Date of Birth: __________________(DD­ MM­YYYY)      6. Sex (Male/Female): _______________

       7.  Physically Challenged (Y/N) : ___________      If yes, please specify : _______________________

8. Nationality : _________________________

9. Passport details :    Passport no.: __________________  Date of issue:  _____________________                                          Valid upto  :  __________________   Place of issue: _____________________

Paste     (do   not   pin) passport size photograph in this space 

10. (a)  Performance in Competitive Examination (such as GRE, GMAT)

Name of the exam: __________________________     Year: ___________        Score:  ________________

(b) Proficiency in English (TOEFL / IELTS)

Name of the exam: __________________________     Year: ___________        Score:  ________________

11. Details of  Academic Record (Secondary onwards)(Mention if the degree is through Distance Education Programme)

Exam Passed/Appeared

Branch

Subject

University/ Institute Month & Year of Passing

Class/ Division

% of Marks

Grade/CPI/CGPA

12. Research/ Professional Experience, Papers published etc.: (Attach a separate sheet for details, if required)

Name of University/ Institute/ Industry

Period Position held/ Nature of duties

Name of Supervisor

Title of Dissertation/ Topic of Research/ Papers Published*

* give title of paper, name of author(s), journal name, volume, page(s), year in a separate sheet.

13.  Employment details :                                                                                                       Total Duration(in months): _________

Name  and Address of the Organization Designation Period 

From (MM­YYYY) 

To(MM­YYYY) 

14. Declaration: I certify that the information given above is correct.  I am fully aware that I must submit attested copies of my qualifying degree certificate / final transcripts on or before joining IIT Bombay, failing which, my admission will stand cancelled.  I am also aware that providing incorrect information in the application form can result in the cancellation of my admission at any stage.

Place:                                                           Date:                                                                                  Signature of the Applicant    

Last date of receipt of completed application form : Autumn semester (15   th   January of every year) & Spring semester (15   th   July of every year)