APPLICATIONS FOR 2017 SCHOLARSHIPS

SAMPLE APPLICATION FORM

This is a sample application form only, it can be used as a tool to plan your application but should not be used to make your submission. Applications are to be submitted using the online form at will be available when applications are open between 1 September and 31 October 2016.

Please note: this form is subject to change prior to applications being received.

  1. Applicant Details

Title: (e.g. Mr, Mrs, Dr, etc.)______First name: ______

Surname/Family Name: ______

Address: ______

______

______

Telephone number:______

E-mail: ______Date of birth:______

  1. Qualifications

Qualifications and date obtained:

  1. Current Employment

Current post:

Duration of post:

Source of funding for stipend/salary:

Current supervisor:

Supervisor postal address:

Supervisor e-mail address:

  1. About Your Home Institution

Home institution name:

Home institution address:

Home institution geographic location:

Name, address (if different from above) and e-mail address for Head of Department:

  1. About Your Host Institution

Host institution name:

Host institution address:

Host institution geographic location:

Reason you wish to visit this specific institution:

  1. About Your Proposed Placement

Placement start date:

Placement end date:

Placement duration:

  1. Summary of Proposed Placement
  1. Statement of Purpose of Visit
  1. Your Current Job Summary
  1. Supporting documentation

You will need toinclude the following documents in order to complete your application:

  • CV which includes your list of publications
  • Letter(s) of support from both supervisor and head of department at your home institution
  • Letter of confirmation that the arrangements proposed are agreed by the host institution
  • Breakdown of costs of visit (you will be required to complete a budget template which will be available online at the time the applications open)
  • Justification for choice of host institution
  1. Amount requested from HIVRT

Amount requested from HIV Research Trust:

Details of other sources of support obtained, applied for, or to be applied for:

  1. Referees

Provide the nameof two referees (include job title, e-mail address, institution name and address):

1.

2.