ENSF_NGO - Application Form
(to be sent to prof. K. Tahir Shah, CEO of ENSF-NGO, Viale Miramare 129 - 34014 Trieste (ITALY))
General Informations
Surname (family name):
First name(s):
Gender:
Male:
Female:
Nationality:
Date of birth:
Place of birth:
Passport #:
Date and place issued:
Expiry date:
Applicant's contact address:
Phone#:
Fax#:
E-mail:
Name and contact details of a person to be contacted in case of an emergency:
Phone#:
Fax#:
E-mail:
Name & Address of Institution where employed (supporting statement by the employer in favour of the grant application must be attached)
Name and Title of the Head of your institution:
Phone:
E-mail:
Position:
Duties and work done:
Fax:
Is the post regular or temporary:
Regular:
Temporary:
Academic/professional information
Degrees awarded
Grade
Year
Field/Discipline
University
Academic/professional employment
Name and address
of past employer(s)
From
To
Position
Duties and work done
Referees. Names and addresses of three senior scientist familiar with applicant's work
Referee Relationship
What is your mother tongue ?
Language skills
ENGLISH
Excellent
Good
Poor
Understanding spoken language
Reading
Speaking
Writing
What is your working language (if other than English) ?
Fellowship details
Name and address of the Institution/conference organization which has accepted you
Name of the laboratory:
Address:
Previous visits, if any, to this laboratory (please give dates and purposes):
Other academic travel abroad in the last three years:
Field/Areaof proposed research/study:
Proposed project. Please provide a detailed description (synopsis) of the proposed study/reasearch plan
Title of the project:
Purpose of the visit:
Outlne of project:
How will the intended research help in your career development ?
Other information
How did you find out about ENSF ?
Direct mailing(to institution)
ENSF-NGO website
Word of mouth/email from a collague
Other, please specify
ENSF
Viale Miramare 129 Trieste Italy
www.ensf-ngo.org