PART I: Application for an International Course Programme (ICP) in 1999-2000 or an International Training Programme (ITP) in 1999
| ICP/ITP applied for (use the name of the course as indicated in the brochure): | Period: |
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1. Personal information
PLEASE NOTE: You must write your name in exactly the same way in this form and throughout the application procedure, otherwise you might experience difficulties when applying for a visa or plane ticket.
Family name (surname): ______________________________________________________
Maiden and/or any other names that may have been used on documents: _______________
First name (given name): ______________________________________________________
Sex (male/female): ______
Place of birth (country, town): ______
Date of birth (dd/mm/yy): _____/___________ / ______
Nationality at birth: ________________
Current nationality: ________________
Permanent address (as mentioned in your passport):
Street, (box) number: ___________________________________________________
Postal code: ______________ City, State: ______________________________
Country: ______________________
Telephone number (country code - area code – phone number): __________________
Fax number (country code - area code – phone number): ________________________
E-mail: __________________________________
Current address (for correspondence regarding this application, especially in the period May – Sept. 1999):
Name of contact person (if applicable): _______________________________________
Street, (box) number: ___________________________________________________
Postal code: ______________ City, State: ______________________________
Country: ______________________
Telephone number (country code - area code – phone number): __________________
Fax number (country code - area code – phone number): ________________________
E-mail: __________________________________
Current address valid until: _________(changes in the address must be forwarded to us!)
Contact person in case of emergency:
Family name: __________________________ First name: _____________________
Street, (box) number: ___________________________________________________
Postal code: ______________ City, State: ______________________________
Country: ______________________
Telephone number (country code - area code – phone number): __________________
Fax number (country code - area code – phone number): ________________________
E-mail: __________________________________
Marital status: married / single / divorced / widowed
If married or having children:
| Surname / Family name | First name / Given name | Date of birth (dd/mm/yy) |
Place of birth | Sex (M/F) |
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Spouse |
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Children |
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2. Language skills
| Mother tongue: | |||||||
| Other languages: indicate with a
number from 1 to 5 the degree of your knowledge: 1 = native speaker, 2 = excellent, 3 = very good, 4 = good, 5 = fair |
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English |
French |
Dutch |
German |
Spanish |
… |
… |
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| speaking | |||||||
| writing | |||||||
| reading | |||||||
| understanding | |||||||
If you are applying for a course/training programme in which English is the medium of instruction:
Was part of your education in English: YES / NO
Do you have a TOEFL certificate: YES / NO
3. Education
Secondary studies (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of the institution |
Name of studies | Qualifications obtained | Grade/ Results |
Post-secondary education or university studies (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of the institution |
Name of studies | Language used | Qualifications obtained | Grade/ Results |
| Title and subject of thesis (also mention the results or grade obtained): |
Other formal studies, workshops, etc. (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of the institution | Name of studies | Language used | Qualifications obtained | Grade/ Results |
Overview of non-formal additional training attended (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of institution Name of supervisor |
Subject |
4. Scholarship history
If applicable, list the scholarships and grants you received previously (in your own country and/or abroad):
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of the organization which issued the scholarship | Studies performed (institution, name of studies) |
5. Academic professional experience
Research and teaching experience (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of institution Name of supervisor Fax and telephone numbers |
Name of subjects taught and/or
description of research conducted, job title (Please distinguish between research and teaching jobs) |
List of publications
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6. Non-academic professional experience (chronological)
| Period from (dd/mm/yy) to (dd/mm/yy) |
Name and address of employer Name of supervisor Fax and telephone numbers |
Position (job title) AND Description of responsibilities |
Sector (education, industry, NGO, etc.) |
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7. Extracurricular record
List extracurricular activities (school or community) in which you have been involved. Use a separate sheet if necessary, but do not exceed 1 page of text.
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8. Motivation
Describe your reasons for wishing to attend this course / training programme. Use a separate sheet if necessary, but do not exceed 1 page of text.
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9. Future plans
Describe your future plans.
How will this course / training programme be useful to the further development of your career?
If you are to be employed after completing this course / training programme, how will this education be useful in your future profession? Also, give the name, address, phone and fax numbers of your future employer. If applicable, add a declaration from your future employer explaining the importance of this course / training programme.
Use a separate sheet if necessary, but do not exceed 1 page of text.
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10. Financial resources
If you are not applying for a VL.I.R. scholarship, you are required to provide evidence of sufficient funds to cover academic and living expenses. You must certify that you will have a minimum income of at least BEF 25,000 (620 euros) per month for the entire duration of the intended study period in Belgium. If you intend to bring your family to Belgium, you must provide evidence of a higher income.
Are you applying for a scholarship to attend this course / training programme, other than the VL.I.R. scholarship? YES / NO
If so: - name of scholarship agency (institution, etc.): __________________________
- address and contact person at the scholarship agency: __________________
- amount: ___________________
- period covered: _______________________
- Have you received confirmation that you will be granted this scholarship? YES /NO
- If so, attach a copy of this confirmation letter.
- If not, when do you expect to receive an answer to your application? ___________
What other sources of funds could you dispose of during your study period?
| Source | Amount (in USD)/month |
| Self support | USD |
| Family or individual sponsors | USD |
| Government, company or other scholarships/grants | USD |
| … | USD |
| … | USD |
Do you plan to bring your spouse and/or children to Belgium? YES /NO
If so, when will they travel to Belgium? _________________________
11. Additional information
Provide any useful additional information. Use a separate sheet if necessary, but do not exceed 1 page of text.
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12. Referees
Give the name of two referees. State their function and give their telephone and fax numbers, as well as their e-mail addresses, if applicable. If possible, one of the references should be from the institution at which you are presently employed.
Enclose two letters of recommendation, if available. These letters of recommendation should detail the following: how long the referee has known you; how well he/she thinks you are capable of adapting to different working and living conditions; your main strengths and weaknesses in a professional/scientific context. The letters of recommendation must be enclosed in a sealed envelope, signed across the back flap.
| Name of referee | Contact address, phone & fax, e-mail address | Your relationship to this person |
13. Additional questions
If so, which ones and what was the outcome?
| Programme | Outcome |
PART II: APPLICATION FOR A VL.I.R SCHOLARSHIP
1. Motivation
Enclose a separate letter detailing your reasons for applying for a VL.I.R. scholarship.
2. Work plans
If you are applying for an International Training Programme: what are your study and work plans, both during and after your training course? Use a separate sheet if necessary, but do not exceed 1 page of text.
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3. Use of knowledge upon return to your home country
How will you use the knowledge you have acquired upon returning to your home country? How will it fit in with your future profession? Use a separate sheet if necessary, but do not exceed 1 page of text.
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4. Transfer of knowledge upon returning to your home country
How will you transfer the acquired knowledge upon returning to your home country? Who will benefit from your knowledge? Use a separate sheet if necessary, but do not exceed 1 page of text.
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5. Financial resources
Have you applied for other scholarships to attend this course / training programme earlier? YES / NO
If so, what was the result of your application?
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PART III: Declaration by the applicant (to be completed by all applicants)
forms
I hereby declare on my word of honour that this information is correct and complete and that I shall immediately inform the VL.I.R. of any changes in my situation, including my family situation.
I shall immediately inform the VL.I.R. of any additional income from another scholarship, allowance or employment.
I hereby agree that any false statement I make in this application shall result in the immediate cancellation of my scholarship.
Name: _______________________________________________
Signature:
Date: ____________________________