Deadline:27 January 2017 at 11:59 P.M. Pacific Time

NEF Fellows Application

Please ensure you have read the eligibility requirements and criteria for selection. For more information: nef.org. Please provide CV and application in PDF format named in the following way: Last name, first name – country.

Deadline:27 January 2017 at 11:59 p.m. Pacific time

Please provide your contact information (all fields mandatory):

First name:

Last name:

Date of birth (YYYY/MM/DD):

Nationality:

Mailing address:

City:

State/Province/County (N/A if not applicable):

Postal Code (N/A if not applicable):

Country:

Phone number:

Email:

We want to get to know you better and to do this we would love to hear you speak to us by video. In the video, please:

a)Tell us about yourself

b)Tell us about your previous work, clearly demonstrating impact both locally and globally

c)Why you should be a NEF Fellow (“I ‘believe I’ am a NEF Fellow …”)

The video does not have to be professionally done (it can be taken with a camera or phone, for example) as long as image and sound are clear. It should not be more than three minutes. Please note that a clear and well-presented video will positively impact your application.

Please provide YouTube link here (make it public):

Answer the following questions in no more than 250 words each in the space provided:

What would you do with the opportunity of being showcased as a NEF Fellow?

What three (3) research questions do you want to know the answers to? Alternatively, please give brief details of a major breakthrough or innovation in your field that you have led or are in the process of finalizing.

Which three (3) leaders in your field, or thought leaders in general would you want to bring on stage with you at the NEF Global Gathering 2018 and why?

Please submit the name of two referees who can speak to your research/work and potential as a leading young African scientist, technologist or social scientist.

Include their name, title(s), contact details (address, email and phone number), your relationship to this person and why this person is suitable to be a referee.

Referee 1:

First Name:

Last Name:

Mailing Address:

Phone number:

Email:

What is your relationship with the referee? (max 150 words)

Why is this person suitable as a referee? (max 150 words)

Referee 2:

First Name:

Last Name:

Mailing Address:

Phone number:

Email:

What is your relationship with the referee? (max 150 words)

Why is this person suitable as a referee? (max 150 words)

By submitting this application, I agree that my name, photo, video and other information may be used on the NEF promotional materials and social media platforms and grant permission to AIMS and the Next Einstein Forum to use them.

Initial here:

Ihereby certifythatthe information submitted on this formand in the attached documents is true and accurate to the best of my knowledge.

Signature:

Please note that if you do not have an electronic signature, you can print, sign and scan application form.

Date: