Application for Fogarty Phd Scholarship In

APPLICATION FOR FOGARTY PHD SCHOLARSHIP IN

HIV-ASSOCIATED TUBERCULOSIS

The information given on this form will be an assessment of the eligibility of the candidate. All personal data will be held in confidence and not disclosed to any third party under any circumstances without permission.

Q1 / CANDIDATE’S DETAILS
(a) / Surname: / Forenames:
Title (Dr, Ms, Mr): / Nationality:
Contact address:
Work tel no.: / Email address:
(b) / Current position:
Current institution & address:
(c) / Education/training:
Date (mm/yy) / Degrees and
diplomas / Subject / University/Institution
(d) / Previous posts: (list the most recent first)
Dates (dd/mm/yy) / Position and source of funding / University/Institution

215 Euston Road London NW1 2BE UK

T +44 (0)20 7611 8888 F +44 (0)20 7611 8545

Registered charity No. 210183 Trustee: The Wellcome Trust Limited Registered in England No.271100 Registered Office: 215 Euston Road, London NW1 2BE

(e) / Candidate’s publications (List all publications including any “in press”) Please separate into the categories original research, reviews and editorials, case reports and abstracts
(f) / Candidate’s other research outputs (e.g. research presentations at annual meetings, conference posters)
Q2 / RESEARCH PROJECT APPLYING FOR:
(a) / Proposed start date: / Period for which support is sought (in months):
(b) / Project title:
(c) / Outline how your experience and research interests fit with the project (max 500 words)
Q3 / OUTLINE HOW THIS AWARD WOULD CONTRIBUTE TO YOUR CAREER (500 words)
Include reference to your education and training hitherto and what you expect to be doing in 5 and 10 years’ respectively
Q4 / EQUITY
This scheme is open to all persons who fulfil scientific eligibility criteria. Assessment will be based on the potential of the candidate.The University of Cape Town and this Fogarty Training Program are committed to demographic transformation and equity, and the imperative to provide research training opportunities to black South Africans will be factored in the selection process.
1. Sex: / Male / Female
2. Date of birth:
3. Nationality:
4. Ethnic origin: / White
Coloured
Black African
Indian
Other / Please describe:
Q5 / HOW DID YOU HEAR ABOUT THESE AWARDS?

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