2009 Pb Application Form

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Name: University: Please PRINT your email address CLEARLY Tell us immediately if it changes →

Your Email:

PROSPECT BURMA Scholarship Application form 2009 For courses in all countries other than India ♦

Please read the guidance notes carefully; answer ALL questions fully in English in black ink

♦

APPLICATIONS MUST BE SUBMITTED TO THE ADDRESS SHOWN IN THE GUIDANCE NOTES BY 31 MARCH 2009

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We do NOT acknowledge receipt of applications. If you have not heard from us by 31 July, you should assume that your application was unsuccessful SUMMARY OF YOUR APPLICATION

Name:

Date of Birth:

Male/Female:

Ethnic origin

Level of Degree studying for:

Subject:

Course ends (month/year):

Funding requested (state amount & currency):

FOR OFFICE USE ONLY. DO NOT WRITE ANYTHING BELOW Registered:

New Student:

Yes/No

Previous study report received: Course enrolment confirmed: References: Sent for

Offer of Place: Received

Checked

Scholarship C’tee decision: Applicant shortlisted : Final decision:

Reject

□

Accept

□

Yes/No Amount granted:

Successful applicant notified: Grant letter issued: Funds transferred on: Notes:

Returned signed: Receipt acknowledged:

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1. YOUR PERSONAL DETAILS Full Name: Date of Birth

Aliases (if any): Place of Birth

Male/Female

Ethnic origin:

Married/Single

No. of Children

Mailing Address:

City:

Post Code:

Telephone: (country code & number)

Country: Fax:

E-Mail:

Details of passport or other travel document: Number: Issuing Authority: Place & Date of issue: 2. PARENTS If either or both parents are retired or deceased, please give their previous occupation Father: Name Country of residence:

Occupation:

Mother: Name Country of residence:

Occupation:

3. STUDENT STATUS: Delete one of the following: a) I have applied to:

Name of university /college:

b) I have been accepted for : c) I am continuing my studies at :

Address of your university/college:

Post Code:

Country:

Telephone:

Email:

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Name:

Are you currently enrolled in a first degree (undergraduate) course?

YES/NO

If YES, attach documentation confirming that you are registered as a student and include a transcript of your most recent year of study. Are you currently enrolled on a postgraduate degree course?

YES/NO

If YES, attach documentation confirming that you are registered as a student. Do you have a confirmed offer of a place on a postgraduate degree course?

YES/NO

If YES, attach a copy of the offer.

If you cannot attach all the required documents when submitting your application, please explain the reasons in a covering letter; and send the documents as soon as they are available. Applications without all necessary supporting documents will be rejected. You may attach further documents if you think they will help your application. 4. DETAILS OF YOUR COURSE: Title: Is the course?

FULL TIME PART TIME CORRESPONDENCE (Please delete as appropriate) Starting Date: (Month/Year) Expected finishing/graduating date: (Month/Year) What is your main subject of study? What is the title of your thesis? (If appropriate) What qualification do you hope to receive from this course, eg BA, BSc, MA, MSc. Ph.D?

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Name: 5. PREVIOUS EDUCATION a.

Name & location of Secondary School attended:

b. Subjects studied:

Examinations passed with dates:

c. Details of College/University attendance:

Examinations passed with dates:

d. Details of any formal English language tuition/examinations passed:

6. REFERENCES Names and addresses of people who can comment on your academic ability (one of these must be your current or most recent academic supervisor): First Referee

Second Referee

Name:

Name:

Address:

Address:

Telephone:

Telephone:

Fax:

Fax:

Email:

Email:

Attach at least one written academic reference. If you fail to give the names of ACADEMIC referees, it will delay consideration of your application. Names of friends, other students or relations ARE NOT ACCEPTABLE.

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Name: 7. FINANCIAL QUESTIONS a.

EXPENDITURE: How much are your annual academic fees & living expenses? Make clear the currency used (US Dollars, Pounds sterling, Thai baht, Indian rupees etc)

Currency Tuition Fees per year Registration fees Books & other materials Other academic fees Accommodation Food Local Travel Other expenses (specify) TOTAL EXPENDITURE

b.

INCOME: Sources of Financial Support for the academic year. Please indicate whether the amounts are assured, or if you have made an application. Include applications to the Open Society Institute (OSI) or other funders. Details

Applied for? Or Certain?

Amount

Own Funds Parents/relatives/other individuals Other scholarships/ grants/ fee waiver Part time work Other TOTAL INCOME NET FUNDING REQUIRED (total expenditure minus total income) ……………………………

FAILURE TO DISCLOSE ALL OTHER FINANCIAL SUPPORT, GIVEN NOW OR AT A LATER DATE, WILL RESULT IN DISQUALIFICATION 2009

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Name: c. Details of your bank account: Name of Bank and branch address:

Name in which account is held:

SWIFT code:*

Account number:

Bank clearing code (if any)*:

We prefer that you have your own account, but if you use a friend’s account, be sure they agree. *Ask your bank for the codes needed for international bank transfers Prospect Burma only offers partial awards; how will you cover the rest of your expenses?

8.

BIOGRAPHY:

Give details of your connection with, and dates of residence in Burma and in your present country of residence. Tell us also of your reasons for choosing your course of study.

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Name: 9. FUTURE PLANS : This section is very important. The essay must be your own. Candidates submitting identical essays will be disqualified. We will give preference to candidates studying subjects relevant to the development of Burma. Please use this space to tell us in your own words about your future plans, and how you will benefit Burma. Continue on a separate sheet of paper if necessary and sign it.

Signature…………………………………………………………….Date…………………………… If you are awarded a scholarship, we will ask you to sign an undertaking that you firmly intend to return to Burma when feasible to help your country’s development. If we have already awarded you a grant, we will not consider another application unless we have received a study report from you. 2009