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Ph.D.ADMISSIONS(JULY/JANUARY)Year20____
Thisformismeantforforeignstudentsonly
Ph.D.Programmein:
(i) _________________________________________________________________
(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)