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 INDIAN INSTITUTE OF TECHNOLOGY BOMBAY
Powai,
Mumbai – 400 076
Ph.D. Admission (July/January) Year 20_ _­ _ _
Paste passport size photograph in this space
( This form is meant for foreign students FRN­TA only)
IITB IITB­MONASH
Application for IIT Bombay
IITB Monash Academy
(please tick appropriate)
Details of payment of application fee:
Bank's name ____________________Banker's Cheque No. _______________ Date:________$/Rs: _____
Programme in : i) __________________________________________
1. Name in full (In capital letters as in qualifying degree certificate)
(Type or Write Legibly in English – Keep one block blank between two words)
2. Category under which you want to apply : FRN­TA (Foreign National – Teaching Assistantship)
3. (a) Address for postal communication* :
b) Name & Address of Parent/Guardian
(i.e. Permanent Address) for postal communication _______________________________________________ ______________________________________________
________________________________________________ _____________________________________________
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 STD code) Mobile No*: E­mail Address(s) *: * Candidate must provide E­mail address or Mobile number or both. Notifications will be sent by email and /or SMS.
5. Date of Birth: (as in School Leaving Certificate): ____________(DD/MM/YYYY)
6a. Birth category : 6b. Person with Disability (Y/N) : 7. Sex (M/F): 8. Nationality : _____________
9. Passport details : Passport No : _______________________________________ Date of Issue _________________________
Valid up to : _______________________________________ Place of Issue _________________________
10a). Performance in Competitive Examination (such as GRE, GMAT / TOFEL etc. ) :
Name of Examination
Score
Year
Valid up to b). Proficiency in English (TOEFL/IELTS)
Name of Examination
Year
Score
12 . Areas of your research interest ( in order of preference : i) ___________________________________________ ii) ______________________________________________
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Contd. on page..2..
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13. Details of Academic Record (Secondary Onward):(Mention, if the degree is through Distance Education programme)
Degree
(list all degrees, Graduate/ Postgraduate)
Name of Degree
Branch/ Name of University/ Mode of Discipline/
Institute
Programme (B.E./B.Tech./ Specialization ( Write full name)
(Regular/Part­
Month & Year of Passing/
time/Correspond Result ence)
Awaited
M.Sc./M.E./ M.Tech./MBA etc.)
% of Class/ marks/ Division
CPI / CGPA (on the scale of 10)
Qualifying degree
(will be used for shortlisting application)
Other degree­1
Other degree­2
Other degree­3
Other degree­4
14. Research/ Professional Experience, Papers published etc.: ( please bring a copy of your publications and thesis if you are called for written test and/or interview. 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*
* mandatory to give title of paper, name of author(s), journal name, volume, page(s), year.
15 : Statement of Purpose : please check the format as provided in the Information Brochure under Appendix­2.
16. Employment details (after acquiring the qualifying degree):
Total Duration(in months): _________
Name and Address of the Organization
Designation
Period From To
(MM­YYYY) (MM­YYYY) 15. Present status : (Employed /Not Employed ) ________________
16. 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 canceled. 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
http://www1.iitb.ac.in/academic/phd.jsp
[please email a copy of the application form to : dean.ir.office@iitb.ac.in
]
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