University of Tehran
2016-2017
APPLICATION FORM
PhD Program
Admission to Center for International Religious Studies (CIRS)
www.cirs.ut.ac.ir
SECTION ONE: PhD Program
Legal Name of Applicant:
……………………………… ……………………………… ………………………………
Last Name First/Given Name Middle Name
Country: ………………………………
A. Research Field:
(Write the applicable choices of the Research Field from the categories A, B, C, D or provided below)
First Choice: ………………………………
Second Choice ………………………………
Third Choice ………………………………
Forth Choice ………………………………
B. Research Project: ………………………………
C. Academic Society:
□ I belong to ……………………………………………….. (Name of the Academic Society)
□ None
D. Educational Background:
List in the chronological order, all schools attended from elementary school
a. / School / location of school(village/town/city) / Period of Attendance / Certificate
1.
2.
3.
4.
5.
For academic studies, state details ‘undergraduate’ ‘major’
b. / college/university / Location of College /university / Period of Attendance / Degree1.
2.
3.
For masters state ‘department’ and ‘major’
c. / Graduate Studies / Department/Major / Location of the Academic Institute / Period of Attendance / Degree obtained or expected1.
2.
d. / Post Graduate Studies -Research Field or Project
1.
2.
Total Period of Education ………………………………………………..
E. Professional Background:
Please list all full time position in chronological order
Academic Institute/OrganizationAgency/Company / Commencement
Termination
Year- Month / Job Title
City/country / Reason/Reasons
for temination
1.
2.
3.
4.
5.
6.
Total Period of Professional Experience
Years / Months
E. Currernt Status
□ Employed
□ Self employed
□ Student
□ Others ………………………………
F. The Latest Position/Post:
1. ……………………………………………………………………………………………..
Organization/ Agency/ Industry/Company
2. ……………………………………………………………………………………………..
Department/Section
3. ……………………………………………………………………………………………..
Number of Employees
4. ……………………………………………………………………………………………..
Date of Employment to Current Position
5. ……………………………………………………………………………………………..
Employment Period Year Month
6. ……………………………………………………………………………………………..
Initial Gross Income Present Gross Income
7. ……………………………………………………………………………………………..
Your Innovative Measures Tangible Effectiveness and Influence
G. Verification:
May we contact your employee? Whom may we contact?
Yes No
______
______
Title Direct Telephone
H. Proficiency in Farsi Language
1. Proficiency in Farsi Language is a must.
2, Qualified and successful candidates with no Farsi Proficiency Certification will be required to
attend Farsi Proficiency Course for a period between 6 to 9 months.
3. The best=select students will receive full grant for the duration of the course.
4. The rest of the students will receive scholarship in partial grant for the duration of the course.
5. Candidates claiming to have proficiency in Farsi must submit authentic certifications in
accordance to the criteria and standards set by University of Tehran. The same rule applies for
other languages, However, the medium of instruction is Farsi in for your PhD Course.
a, Proficiency in Farsi Language
Listening / Excellent / Good / Satisfactory / PoorSpeaking / Excellent / Good / Satisfactory / Poor
Reading / Excellent / Good / Satisfactory / Poor
Writing / Excellent / Good / Satisfactory / Poor
b, Proficiency in Other Foreign Languages
______
2nd Language Your Mother Language
Listening / Excellent / Good / Satisfactory / PoorSpeaking / Excellent / Good / Satisfactory / Poor
Reading / Excellent / Good / Satisfactory / Poor
Writing / Excellent / Good / Satisfactory / Poor
Note: Acceptable authenticate certification is a must that can also be varied.
H. Other Language Qualifications (A polyglot) :
c. A fair command
1. ……………………………… 2. ……………………………… 3. ………………………………
……………………………… ………………………………
Certification Name Year month
Note: Submission of an authenticated certification a must.
I. Social and or Volunteer Activities:
a.
………………………………
Activity Description
………………………………………………………………
Agency/Organization/Company/other
………………………………
Village/Town/City ..Country
………………………………………………………………
Period Year month Year nonth
Brief Decription
b. Distinct Research works Agency-wise, national-wise and international-wise recognized.
This factor will greatly facilitate in the process of your selection as a scholarship candidate for a PhD Program.
Brief Description
J. Job Decription:
1. Nature of your work activity 2. Your Responsibility 3, Your Supervision 4. Budget size
5. Effects of Decision 6. Influence of your Achievement
7. Write the detailed account on a separate sheet of A4 sized paper. (About 500 words)
K. For Statistics Purpose Only:
a. Your source of Information about CIRS.
b. What influence your decision to apply for CIRS?
c. Please list your applying for other PhD programs.
SECTION TWO:
A. Personal/Application Information:
1. Legal Name:
Last Name: / Prefix: title Suffix: MD/Junior:First Name: / Middle Name:
2. Other names that may appear on your academic records:
Last Name: / First Name: / Middle Name:3. Legal Sex :
□ Male
□ Female
4. Do you identify as Lesbian, Gay, Bisexual or Transgender (LGBT) .. (Optional):
□ Yes
□ No
□ Not sure
□ Decline to state
5. Birthdate:
Month Day Year
6. Birth Place :
Village/town/city : / Country: / Continent:7. Current Mailing Address:
Street Number: / Street Name: / Apartment:Village/Town/City: / State/Province:
Zip Code : / Country: / Continent:
International Code:
8. Permanent Address if different from current as indicated above:
Street Number: / Street Name: / Apartment:Village/Town/City : / State/Province:
Zip Code:
9. Permanent Residence:
Country of Residence:10. Primary Tel:
11. Cell Phone:
12. E-Mail Address:
E-mail is the primary source of communication with the applicants.
CIRS will send you important messages to you using the e-mail address you list on
this application. It is your responsibility to check the e-mail account
regularly and read your messages from CIRS. Be sure to notify CIRS
if the email address changes.
13. Country of Citizenship:
Citizenship:
□ Refugee
□ Asylee
□ illegal
14. Type of Visa (Specify) :
B. 1. Do your parents or any members of your family claim Iranian
Residency?
□ Yes
□ No
2. Has any members of your family continuously lived in Iran?
□ Yes
□ No
C. Ethnicity:
State clearly what best describes your background?
………………………………………………………………
………………………………………………………………
D. Races:
Iran identifies peoples as African, Asian, Arab or European.
The nation neither discriminates them nor shows preference one over the other. The table is just for the purpose of classification.
□ African / Country:□ Asian / Country:
□ Arab / Country:
□ European / Country:
□ Others / Country:
□ Decline to State / □ None of the Above
E. Military Information:
1. Have you ever served in the military?
□ Yes
□ No
If Yes, please choose correct Status.
□ Conscript
□ Active Duty
□ Reservist
□ Veteran (Retired)
□ Disabled
2. Please indicate the Branch of Service for your above status.
□ Army
□ Air Force
□ Navy
□ Law Enforcement
□ Coast Guard
3. Are you discharged from military service?
□ Yes
□ No
□ Army
□ Air Force
□ Navy
□ Law Enforcement
□ Coast Guard
F. Family, education, income, dependent and independent Students.
Dependent student is defined as married, has dependents other than Spouse, a foster youth, orphan, ward of the court.
Please indicate parents’/guardians’ total annual income of the
year 2017 and enter in the box.
1. Dependent Student. Only estimated 2017.
Total Annual Income / Family Size2. Independent Student. Only estimated 2017.
Total Annual Income / Family SizeNumber of depedent students living with you 2017. ……………………….
3. What are your parents’/guardians’ highest level of education? (OPTIONAL)
Enter Code in the box.
□ Male
□ Female
a. No High School b. Some High School c. High School Graduate
d. Some College e. 2 Year College f. 4 Year College Graduate
g. Post Graduate
G. Religion:
□ Moslem
□ Christian
□ Jew
□ Hindu
□ Buddhist
□ Other
H. Campus Housing:
Subject to application and availability, if you plan to live in
Campus Housing enter a Yes in the box.