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Chulabhorn Graduate Institute - The ASEAN Foundation

Joint Post-Graduate Scholarship Program

Scholarship Application Form

(for ASEAN Applicants)

Place

Photograph

Here

IMPORTANT INSTRUCTIONS:

 Each question must be answered clearly and completely.

 Duly completed application forms should be forwarded to the Chulabhorn Graduate Institute before deadline of application

Incomplete applications will not be considered.

Proposed field of study: Applied Biological Sciences: Environmental Health

Environmental Toxicology

Chemical Biology

PERSONAL DATA

Title Family name / Surname

(as shown in passport) First name Sex

City and country of birth Nationality Date of Birth

(DD/MM/YY) Age MaritalStatus Religion

Single

Married

(2)

COMMUNICATION AND MAILING ADDRESS

Applicant’s Office Address: Applicant’s Home Address:

Office telephone NO:

Country| Area| Number

FAX:

Country| Area| Number

Home telephone NO:

Country| Area| Number

FAX:

Country| Area| Number

Office Email: Personal Email:

Name and address of person to be notified in case of emergency:

Telephone No: ……… Relationship: ………..

Country| Area| Number

International Airport / City of Departure

EDUCATION RECORD

Education Institution City/ Country

Years Attended Degrees, Diplomas and Certificates

Have you ever been trained in Thailand? If yes, what course, where and for how long?

List of your publications/researches (do not attach details)

(3)

sssss

EMPLOYMENT RECORD

Present or most recent post: Previous post:

Employer: Employer:

Years of service (from-to): Years of service (from-to):

Title of your post/position: Title of your post/position:

Type of your organization:

Government/ Semi Government/ Private/ NGO

Type of your organization:

Government/ Semi Government/ Private/ NGO

Main function of the organization: Main function of the organization:

Office address: Office address:

(4)

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EXPECTATIONS

Please describe the practical use you will make of this study on your return home in relation to the responsibilities you expect to assume and the condition existing in your country in the field of your training. (Please continue on supplementary pages if necessary)

LANGUAGES (No consideration will be given to applicants without language proficiency test documents)

Read Write Speak

Excellent Good Fair Excellent Good Fair Excellent Good Fair

Mother tongue

………

English

Other

English Proficiency Test* (please attach)

TOEFL Score ………….. IELTS Score ………..

Other (specify)

*Required Information

(5)

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