STFC GEMINI STUDENTSHIPS 2009

APPLICATION FORM FOR THE 2009-2012 CYCLE

You must complete all sections of this form clearly and in full.

THE INFORMATION YOU PROVIDE WILL BE TREATED IN STRICT CONFIDENCE

APPLICATIONS SHOULD REACH CONICYT BY NOVEMBER 28, 2008

1. Name in full R.U.T.

2. Present address for correspondence:

Street / City
Telephone: / Mobile phone: / Fax: / Email:

3. Date of Birth: Age: Place of Birth: Nationality: Citizenship:

Day-Month-Year

4. Gender Marital Status: Number of Children: Age of Children:

Male Female

5. Travelling to the UK:


Alone With Spouse With Children

6. Name of your High School Institution:

7. Scores of the Prueba de selección Universitaria (PSU)

PAA Verbal / PAA Matemática / PAA Historia / PCE Física / PCE Matemática

8. Professional / Academic Degree:

9. Academic Degrees

DEGREES / MAJOR / DATES
AT EACH
Month/year
To / INSTITUTION
From / From

Thesis title______

______

Thesis advisor ______

10. Relevant Education Abroad:

COUNTRY / DATES
Month/ year / INSTITUTION / SUBJECTS DEGREE

11. Experience in teaching and/or research.

NAME OF INSTITUTION / POSITION/RESPONSABILITIES / FROM month/year / TO
month/year

12. Address of present employer:

Street / P.O. Box / City
Telephone: / Fax: / Email:

13. List of scholarships or fellowships held at present or in the past (give source or sponsor, amount, where held and duration):

14. Competence in English: Formal studies in English:

a) Name of institution:

/ b) Certificates obtained: / c) Length of period studied:
TOEFL Examination date ______Test score ______OR
IELTS Examination date ______Test score ______
Self Assessment of proficiency in English:
Excellent ﾐ Good ﾐ Fair ﾐ Poor ﾐ Other Languages ______

15. Proposed Host Institutions. (See Attached List “Gemini Scheme Participants”)

a) FIRST CHOICE
University/Department:
Research Topics:
Faculty contact:
b) SECOND CHOICE
University/Department:
Research Topics:
Faculty contact:

16. OTHER SCHOLARSHIPS / GRANTS


Have you applied or intend to apply to another organization for a scholarship to study abroad?
Yes No
If so, please give details which include: Name of organization, type of scholarship and estimated date of announcement of results:

17. Name of Recommenders (Two Letters of Reference):

Name and Institution: ______

Name and Institution: ______

______

APPLICANT’S NAME AND SIGNATURE DATE

STFC GEMINI STUDENTSHIPS - 2009

LETTER OF REFERENCE

NAME OF APPLICANT: ______

Name and title of recommender ____________

Position ______

University/Faculty/Department ______

How long and in what capacity have you known the applicant? ______

PART 1.

Using the chart below, please rate the applicant in comparison with others you have known in the same field.

Outstanding / Excellent / Good / Fair / Poor / Unable to judge
1. Academic performance
2. Intellectual ability
3. Motivation
4.  Potential to contribute to the field of Astronomy in Chile
5. Adaptability to new situations
6. Ability in: Oral expression
Written expression

PART II.

Please provide a narrative description of the applicant’s qualifications for advanced graduate study. Assess candidly the individual’s academic qualifications, potential to carry out advanced study in the field specified, intellectual independence, capacity for individual thinking, ability to organize and express ideas clearly, and potential for teaching.

It is important that your statement be as complete and specific as possible. Please answer Part II on a separate sheet with official letterhead.

Signature Date

IMPORTANT: All documents which are not in English must be accompanied by a translation into English.

PLEASE NOTE THAT YOUR APPLICATION WILL NOT BE CONSIDERED UNLESS ACCOMPANIED BY THE FOLLOWING SUPPORTING DOCUMENTS, WHICH MUST BE PRESENTED IN THIS ORDER AND IN THREE COPIES (original and two photocopies).

CHECKLIST Mark with √

1.  Application Form
2.  Curriculum Vitae.
3.  A brief personal statement.
4.  Copy of the Identification Card.
5.  Copy of your Degree Diploma(s) / Certificate(s).
6.  Copy of University Record (Concentración de Notas Universitarias de pre y postgrado). This should include the grading scale and the total average.
7.  Copy of class ranks (Certificado de Rango).
8.  Score of the Test of English as a Foreign Language (TOEFL) or International English Language Testing System (IELTS).
9.  Research Proposal.
10. Two letters of reference.