INDIAN INSTITUTE OF TECHNOLOGY  BOMBAY

Powai, Mumbai – 400 076

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

.    
This form is meant for foreign students only

                                                                                                Paste     (do   not   pin) 

Ph.D. Programme in : passport size photograph 
in this space 
(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: _____________________
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/ Branch University/ Institute Month &  Class/  % of  Grade/CPI/CGPA
Appeared Year of  Division Marks
Subject Passing

12. Research/ Professional Experience, Papers published etc.: (Attach a separate sheet for details, if 
required)
Name of University/  Period Position held/  Name of  Title of Dissertation/ Topic of 
Institute/ Industry Nature of duties Supervisor 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  To
(MM­YYYY)  (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    January of every year) & Spring semester (15
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      July of every year)
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