Application Form Fellowship

							                                                                                2012 UPEACE-IDRC PHD FELLOWSHIPS
                                                                                        Application Form

                       1. Applicant's Details

  Ms.              o              Mrs.        o                         Mr.          o                                 Other        o

  Surname                                                                                                              Given Name (s)

  Citizenship

  Address

  City                                                Country                                                                                           Postal Code

  Telephone                                                                                                  Cell Phone

  Fax                                                                                                        E-mail


           2. Academic Institution’s Address: -

  Name of University


  Faculty/Department

  Telephone

  Fax

  E-mail

  Contact Person


3. Current Study (Ph.D.) Details
  Title of Research Proposal



  Name of Supervisor

  Faculty/ Department                                                                                                                       Telephone

   Country of Research Focus

  Timeline of Research

  From                                                To                                       Total Number of Months
                                     Month-Year                      Month-Year



           4. Academic Information

                           4.1 Chronological list of academic achievements (all degrees, diplomas and/or certificates prior to your current studies)

                                           Faculty/
             Institution                  Department                          Degree/Diploma/Certificate                            Field of Study              Specialization   Date awarded




                          4.2 Other trainings relevant to this application (Courses/Seminars).
                Course/Seminar                                               Institution                                                     Subject             Month/Year
4.3 Describe the status of your current study (Ph.D. ) in no more than 150 words.




4.4 List all awards including scholarships that you have received.

                                                                                                               Period of Award
                                          Name of Award                                                 From                       To

    1


    2

    3

4.5 Provide details on your contributions to research, such as participation in research projects.




        5. Professional Background
5.1 Chronological list of your work experiences, beginning with the most recent:-


          Starting and Ending Date
           From                      To                              Position                                       Organization




5.2 Describe briefly your current career objectives and its relationship to your proposed research: -
              6. Language Skills
6.1 List languages that you speak, write and read in the following table.
E = Excellent                  G = Good                     F= Fair

                    Language                               Read                    Speak                          Write




              7. Other Information
Please provide any other information that you feel may be useful in assessing your application.




    8. References
List two persons who are familiar with your academic work and willing to submit a confidential recommendation for you.


Name                                                                                     Position

Institution

Address

Telephone                                                                                Fax

E-mail


Name                                                                                     Position

Institution

Address

Telephone                                                                                Fax

E-mail

    I declare that to the best of my knowledge, the information given in this application is true and complete.


   Signature
        Signature                                                                        Date

Note: - This is a reminder that only complete applications received by the deadline will be considered.

We thank all applicants for their interest in this Fellowship. Only those candidates whose academic background and skills best match the criteria of the
Fellowship will be contacted.