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APPLICATION FORM

INSTITUTIONAL FINANCING

CANDIDATE

Title :  Mr  Mrs

SURNAME (maiden name for married women):

USUAL NAME (married name for married women):

First name:

National insurance number: ___| ______| ______ |______| _________ _________ ______

Date of birth: |__|__| |__|__| |__|__||__|__|

Place of birth: Town:______Country: ______

Nationality:

Marital Status :single  married  widowed  divorced  partner

separated partner in a civil solidarity pact

Number of children: |__|__|

Address:

postal code: Town :

Telephone number:

Email:

Professional situation:

Are you in a position of civil servant:  YES  NO

If you are concerned, are you  trainee  permanent employee

Detail your civil servant degree: ______place of nomination ______

Do you have the aggregation:  YES  NO

If you do, point out the wording and year:

PREVIOUS TRAINING

Bac + 5 years of further education diploma:  Master  Engineer  other, tell precisely:

Country where you got it:

School of education:

Date of getting:

Speciality of your diploma:

Do you have the aggregation: YES  NO

Are you a former student from a National Institute: YES, point out which one ______ NO

Distinction:  congratulation  Very good  Good  Quite good  Only average

THESIS

Doctoral Schools :

 n°521 Information Science and Engineering

 n°522 Materiels, Mechanical, Energy and Aeronautical Science and Engineering

 n°523 Enviromental Sciences « Gay Lussac »

 n°524 Biology and health Sciences « Biohealth »

 n°88 Law and Political Science « Pierre Couvrat »

 n°525 Letters, Thought, arts and history « Civilization and Literature from Antiquity to today »

 n°526 Societies and Organisations

 n°527 Cognition, Behavior, language(s)

Research unit:

Title of the thesis:

PhD supervisor:

 Mr  Mrs

Surname: Firstname :

CNUsection: _________

Research Unit:

If there is a joint advisor, detail for each one:

 Mr  Mrs

Surname: Name:

Authorization to direct researches:  Yes  No

CNU Section: _________

Research Unit:
 Mr  Mrs

Surname: Name:

Authorization to direct researches:  Yes  No

CNU Section: _________

Research Unit:

Kind of financing wishes:

 PhD Contract  regional grant (you can check both financing propositions if you are interested by each one)

Would you like to be sessional lecturer:  YES NO

PAPERS TO JOIN with this application form :

 Curriculum Vitae,

 Cover letter with professional plan,

 copy of Master report card and of certificate of achievement,

 thesis project (between 3 et 4 pages),

 one page popularized summary of your thesis project in French

 substantiated recommendation from the PhD supervisor to give you a financial support

 copy of an ID card

These documents have to be return by email at

not later than the June, 11th 2014.

Contact : Claire BUISSON

Université de Limoges – Pôle Recherche - Collège Doctoral

33 rue François Mitterrand - BP 23204 - 87032 Limoges

 : 05 87 50 68 92Fax : 05 55 14 91 08