Ictp-Ansole Fellowship Application Form

ICTP-ANSOLE FELLOWSHIP APPLICATION FORM

FELLOW DATA

Surname and name:

Date and place of birth:

Nationality:

Gender:

Marital status:

Email(s):

Cellphone number(s):

Skype address (optional):

Home address:

Month and year of adhesion to ANSOLE:

Please, insert below applicant´s color passport-sized photo before printing for the various signatures:

INSTITUTION DATA

Name and address of laboratory/department/faculty/institution:

Study program of applicant:

Name and signature of head of laboratory:

Name , signature, and stamp of dean of faculty of the applicant:

FELLOWSHIP

The fellowship is intended to support a study program/research program leading to completion for a Bachelor, Masters or PhD qualification to be conducted at the above-mentioned institutions or the following institution(s) under the supervision of experienced scientists. Each fellowship will be provided 1 year for „ANSUP“ (ANSOLE Sur-Place Fellowship Program) and „ INEX“ (Intra-African Exchange Fellowship Program) programs up to maximum 2 years (Masters) and 3 years (PhD), and is subject to yearly renewal upon submission of satisfactory progress reports of fellows and their supervisors. The ANEX (Africa-North Exchange Fellowship Program) fellowship is a one-time support of maximum 6 months. A final end of fellowship report is submitted by allfellows to the ANSOLE coordination office.

The fellowship requires that the ANSOLE coordination office is informed of other grants, funds, bursaries, support of parents/relatives, etc that have been awarded in connection with the research program

Type of fellowship (delete inapplicable!): ANSUPundergraduate/ ANSUP Masters/ ANSUP PhD/ INEX Masters/ INEX PhD/ ANEX Masters/ ANEX PhD

Period of support: From: (day/month/year); to (day/month/year):

Name and signature of local supervisor (LS):

Month and year of adhesion to ANSOLE of LS:

Name and address of host laboratorry1):

Name and signature of external supervisor (ES)1):

Month and year of adhesion to ANSOLE of ES1):

Field keyword(s)

Title of Thesis:

Date and signature of applicant:

Further requirements: The filled form should be scanned and submitted per email at together with a detailed CV with passport-size photo, University certificates and/or results transcripts, a motivation letter, Research proposal, two recommendation letters, an acceptance letter from the host supervisor and proof of ANSOLE membership of applicants and supervisors, as one PDF file. (To put PDF files together, please go to The documents (2x hardcopy) should be sent to the ANSOLE coordinator, PD Dr. Daniel A. M. Egbe, Institute of Polymeric Materials and Testing (IPMT), Altenbergerstr.69, A-4040 Linz, Austria. Visit for additional details.

For ANSOLE coordination office only

The above-mentioned fellow is entitled to receive a monthly fellowship amounting to Eur………………..from…………………to………………….., in total…...... months, for a TOTAL AMOUNT of …………………….

For INEX and ANEX programs, the fellowship will also reimburse the following expenses upon submission of valid receipts and/or used ticket stubs:

-travel expenses,

-visa/study permit,

-medical insurance (maximum of 100 Euro per year)

Place, date, name, signature and stamp of ANSOLE Coordinator:

1)For INEX and ANEX fellowshipsPage1