APPLICATION FORM KOI 2013: Training Course Road Safety in Asian & Latin American Countries: Principles and Approaches FILL IN THIS FORM IN CLEAR HANDWRITING, IN CAPITAL LETTERS 1. Identity Mr. / Mrs.*: *(delete where not applicable) SURNAME (family name) as on passport: FIRST NAME(S) as on passport:..,.., BORN ON. (DATE dd/mm/yyyy) IN... (PLACE: town/city + country) NATIONALITY:.. HOME ADDRESS (street + number + postal code + town/city + country):........ HOME TELEPHONE NR:..HOME FAX NR HOME EMAIL:.. AFFILIATION/WORK ADDRESS (address local institution) (street + number + postal code + town/city + country):..... WORK TELEPHONE NR:.. WORK FAX NR: WORK EMAIL:.. SINGLE / MARRIED / SEPARATED / DIVORCED / WIDOW(ER) / OTHER (*), NUMBER OF CHILDREN: (*delete where not applicable) PASSPORT NUMBER (if available): NATIVE LANGUAGE CONTACT ADDRESS OF PERSON TO BE NOTIFIED IN CASE OF EMERGENCY (incl. Country code/area code) Name Telephone E-mail Application form KOI 2013, p. 1 of 8
2. Educational background List chronologically starting with the least recent, the details of secondary education and higher education, as well as professional training attended. From To Name and address of the institution Field of study Degree/year* 2.1. secondary education (high school) 2.2. obtained higher education degree (university education and/or non-university programme(s)) 2.3. professional training(s) and/or memberships *degree/year: For higher education: - Degree: fill in whether you obtained a bachelor or master degree - Year: fill in the year of graduation For professional training and/or memberships - Degree: fill in whether this was a training course or is a current membership - Year: fill in the year of the training course or start of the current membership Application form KOI 2013, p. 2 of 8
3. Professional experience 3.1. Current position From to Employer (organization) Location Job title Description of your work, including your personal responsibilities 3.2. Previous position From to Employer (organization) Location Job title Description of your work, including your personal responsibilities Application form KOI 2013, p. 3 of 8
4. English proficiency Indicate what is applicable to you and provide proof of English proficiency: English is my mother tongue or official language of the country Carried out higher academic education (min. 1 year) where English was the medium of instruction (please enclose copy of certificate with your application!). I have taken a TOEFL, IELTS or similar English test (please enclose the results of this test with your application!). Application form KOI 2013, p. 4 of 8
5. Motivation Please state briefly (max ½ A4 page) the reason for applying to this programme, your main field of interest within the programme and how you hope to benefit from the programme. Application form KOI 2013, p. 5 of 8
6. Scholarship info (Note: you can only be considered for a scholarship if you meet the eligibility criteria, set by VLIR-UOS: see website) Indicate whether you wish to apply for either option A, OR option B + select suboption A. I wish to apply for a VLIR-UOS scholarship* A.1. if I do not get a scholarship, I will not be able to participate A.2. if I do not get a scholarship, I am still interested in taking part as a paying participant, either funded by myself or funded by my employer B. I do not need a scholarship and will take part as a paying participant B.1. the tuition fee will be funded by myself personally B.2. the tuition fee will be funded by my employer * Please note that only a limited number of applicants can get a scholarship. A selection of suitable candidates is made according to certain criteria. If you are not selected for a scholarship, please indicate whether you still wish to come as a paying participant or not. 6.1.Did you apply for another VLIR-UOS scholarship in 2013? 6.2. Did you ever receive a master scholarship funded by the Belgian government before? 6.3. Have you received a VLIR-UOS scholarship for a training programme before? if the answer was yes, - what was the title of the course: - who organized the course: - start and end date of the course: - where did the course take place: 6.4. Have you ever received another (non-vlir-uos) scholarship in the past? if the answer was yes, - what was the title of the course: - who organized the course: - start and end date of the course: - where did the course take place: 6.5.a. Do you work for a university? If the answer was yes, please fill in 6.5.b., otherwise skip to 6.6 6.5.b. Does your university currently receive support from VLIR-UOS through the IUC or OI? If the answer was yes, please fill in 6.5.c., otherwise skip to 6.6 6.5.c. Is your department involved in the IUC or OI programme? if the answer was no, please send a letter from the IUC or OI coordinator stating that your department is not involved in IUC or OI. Contact the programme manager in the IUC or OI office at your university for further information. Application form KOI 2013, p. 6 of 8
6.6. Please give a brief motivation why you want to apply for a scholarship (max. 10 lines): Application form KOI 2013, p. 7 of 8
7. Medical statement Select all boxes which are applicable to you I do not have any infectious diseases (for example tuberculosis or trachoma) or any other illnesses which could present risks to persons that I will come in contact with. I do not have any medical conditions which prevent me from carrying out training away from home I am in good health and enjoying full working capacity Comment : I hereby declare that all information in the above application statement is true, Name + signature of applicant: Date: Application procedure: Please send the filled in application form latest by 15 th May 2013 to Hasselt University either by: 1. email to nadine.smeyers@uhasselt.be 2. by fax to +32 11 26 91 98, for the attention of Nadine Smeyers After the application deadline, all complete files will be reviewed. As soon as the admission committee will have decided on your application, you will be informed by Hasselt University (latest end June 2013). A. Scholarship application: o If your application for a scholarship has been accepted, you will receive a reply email or letter explaining the short visa application procedure. o However, if your application for scholarship was denied and you selected application suboption A.2., you will receive an email with payment instructions for the tuition fee of 750 (developing countries)/ 1,500 (developed countries) Euros. If you still wish to enrol, you need to let us know by email to nadine.smeyers@uhasselt.be and pay the tuition fee as per the described procedure. Your enrolment is registered after receipt of your tuition fee. After the tuition fee has been received by Hasselt University, we will send you an official letter of invitation for your visa application. Deadline for payment is therefore 15 th August 2013. B. Non-scholarship application: As soon as the admission committee will have decided on your application (suitability to attend the programme), you will be informed by Hasselt University. If you are admitted you will receive at the same time the reply email with payment instructions for the tuition fee of 750 (developing countries)/ 1,500 (developed countries) Euros. Your enrolment is registered after receipt of your tuition fee. After the tuition fee has been received by Hasselt University, we will send you an official letter of invitation for your visa application. Deadline for payment is therefore 15 th August 2013. Application form KOI 2013, p. 8 of 8