CICOPS SCHOLARSHIPS 2017 APPLICATION FORM

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DEADLINE: May 31st, 2016

1. PERSONAL INFORMATION

Surname / Family Name / Last Name *

First Name / Given Name *

Gender *

Male

Female

Nationality *

Mother tongue *

Other languages

Date of birth *

enter as "dd/mm/yyyy"

Country of birth *

Country of residence *

Permanent Residence Address *

Street address

City *

City

State / Province

Postal / Zip Code

Country

Mailing Address

Same as above

Add a different mailing address

Clear selection

Residential Mailing Address

Street Address

City

State / Province

Postal / Zip Code

Country

Thelephone (enter as "+##.###.######") *

Phone office

Phone home

Mobile

Fax

Email *

This email addess will be used for the selection procedure follow-up. Make sure you read your email on a regular basis.

Skype

2. EMPLOYMENT

Current Employer / Institution *

Please specify: name of the Institution, address, city and telephone number

Current Position / Title *

No. of years of teaching experience

enter as "##"

No. of years of experience working in International Organizations / Institutions

enter as "##"

3. RESEARCH ACTIVITIES

Main areas of Research *

Current Research Activities *

Max 300 words

Past Research Activities

Max 300 words

Relevant Publications

Max 400 words

4. PROPOSED COLLABORATION AT UNIVERSITY OF PAVIA

It is MANDATORY to have an invitation letter from your contact Professor at University of Pavia (see FAQ).

Contact person / collaborator at University of Pavia *

enter as "Name Surname"

No. of years of collaboration (if relevant)

enter as "##"

Department in wich research will be carried out *

Proposed area of joint research or title of research project *

Max 200 words

Keywords

5. PERIOD OF STAY IN PAVIA

Proposed number of weeks (4-12) *

enter as "##"

Proposed dates (be as precise as possible) *

enter as "dd/mm/yyyy - dd/mm/yyyy"

Other informatin/Special Requests

I am aware that any application form without invitation letter will be automatically delated.

Required

I hereby ensure the truthfulness of the above data and authorize the use of my personal details for circulation within the University of Pavia according to the Italian Legislative Decree n. 196/2003. I understand that false declarations are punishable by law, in terms of art. 76 of the DPR 445/2000. False statements and inaccuracies in the declaration may lead to the exclusion from the selection process and/or from the award of the scholarship.

Required

Personal data submitted by the applicants will be used by the University for application and selection procedures and institutional aims solely, in accordance with the Italian Legislative Decree n. 196/2003 (Italian Privacy code). Each applicant has the rights established by art 7 of Decree-Law 196/2003. The treatment of data is under the care of the CICOPS President.

Required

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