DELGEME Application form for Post-Doctoral Scholarship

  1. Personal Information

Title:
Last name:
Maiden name (for married women only):
First Name:
Birth date:
Native country:
Gender (Male or Female):
Nationality:
Current status (student, private sector employee, NGO worker, unemployed, other, etc.). If other, pleasespecify:
  1. Home Address

Address:
P. O Box or postal code:
City:
Country of residence:
Phone:
Fax:
Email 1:
Email 2:
  1. Professional Information

Current job:
Organization:
Department, service:
Position or title:
Address:
Box or postal code:
City:
Country:
Phone:
Fax:
Email 1:
Email 2 :
Duration of your professional experience (Year):
  1. Degrees and certifications

List of all the latest academic degrees (Starting with the highest):

Year / Title of diploma / Mention / SchoolCountry

List of training or professional certifications(Please add lines as needed):

Year / Title / Institution
  1. Research institution

Name of Research institution
Address of research institution
  1. Research project (you may choose to attach a separate PDF file for your project)

Title of the research project:
Summary of the research project :
Description of the research project (scientific scope , detailed definition of the problem and research objectives , Methodology, References ) :
  1. Work plan
  1. Publications (Please add lines as needed)

Publication 1:
Publication 2:
Publication 3:
Publication 4:
Publication 5:
  1. Budget

Budget (field work if applicable, personnel, materials, travel )

Item / Amount
Total

Please indicate any additional source funding for your project

10. Ethical considerations

Will this project involve humanssubjects for?
If yes, Please indicate age ranges?
Will there be animals used in your proposal?
If yes, list the species and number:
Discuss ethical issues relevant to your proposal, if necessary:
Name the regulatory organization to which your proposal will be submitted:

11. Career Plans

Please state your long term career goals and how this Fellowship will help you achieve them? (maximum 500 words)

12. Personal references (Two references)

Last and First names
Title
P.O Box or postal code:
Email:
Phone:
Last and First names
Title
P.O Box or postal code:
Email:
Phone:
  1. Mentor’s reference[1]

Last and First names
Title
P.O Box or postal code:
Email:
Phone:

Signature

I……………………………………………… (name and surname of the candidate) hereby certify the accuracy of the above information

Place and Date ………………………………………………..

[1]Mentorshipis a relationship in which a more experienced/person of greater rank or more knowledgeable helps to teach, guide and develop a less experienced or less knowledgeableperson.