Scholars Program

Contact Information

First Name (Given Name as mentioned in your passport)

Last Name (Surname or Family Name as mentioned in your passport)

Date of Birth:

Gender:

Country of Citizenship:

Passport Number:

Passport Expiration Date:

Street Address:

City:

State:

Postal Code:

Country:

Phone Number:

Mobile Number:

Email Address:

Recent Photograph (Upload): Accepted formats: jpg, png

Emergency Contact Information

Name:

Relation:

Contact Number (Home):

Contact Number (Mobile):

Advanced Degree

Applicant’s Home Institution (Current Employment):

Applicant’s Title at Employment:

Describe your work in 10 words or fewer.

Disciplines

Area of Interest

About You

Share a topic about which you have changed your mind, and explain the reasoning behind your change. Not more than 200 words

How did you educate and influence others to the change in your opinion, and how did or will that change impact the community? Not more than 200 words

Work

What public problem are you working to solve and why? Not more than 200 words

How are you attempting to solve the problem? Not more than 200 words

What concrete impact – however you define impact – is your work having or going to have? Not more than 200 words

What is the next phase of your work? What do you most need to help you achieve it? Not more than 200 words

Scientific Publications (optional)

List scientific publications, if any:

In your own words, please provide three areas of interest that most represent your focus. (Not more than 2 words for each area of interest)

None

Personal Statement

Not more than 200 words

Resume (Bio-sketch or CV)

Files: Accepted formats: MS Word, Adobe PDF or Open Document Format

References

Please provide the names & contact information for three people who are familiar with your work. We are interested in speaking to people who can speak to what you have shared in your application.

Name:

Email:

Phone:

How is person familiar with your work?

Name:

Email:

Phone:

How is person familiar with your work?

Name:

Email:

Phone:

How is person familiar with your work?

Application Form

Contact Information

Emergency Contact Information

Advanced Degree

Disciplines

Area of Interest

About You

Work

Scientific Publications (optional)

Personal Statement

Resume (Bio-sketch or CV)

References