Application Form for the RESEARCH INTERNSHIP Scholarship

Please read the guidelines for application before filling the form!

Passport size photo

Type your information above the black line with font size 10

Do not alter layout of pages when completing the form

Your personal details
Surname Previous surname !if married" %ender &ationality irst name!s" Date of #irth !dd $ mm $ yyyy" Place of #irth 'ighest academic degree obtained

Your field of study

Degree Period for which Scholarship is re)uired !dd$mm$yy*dd$mm$yy" Specialisation sub(ect &umber of +onths

Contact details of your HO

&ame and Surname ,niversity $ -nstitution and Department Designation

! professor in char"e in India

.*mail

Tel/

Your current address

Street0 P/1/ #o2 Postal code 3ountry 3ity$town .*mail +obile/ Tel

Application Form Research Internship Pro"ram # $!%

Contact person and host institution in France

irst &ame and Surname ,niversity$-nstitution Department$-nstitute Street$P/1/ #o2 Postal code 3ity .*mail Tel/

Your application status

Do you have a confirmation of your admission in the rench institution4
3onfirmed
5waited

Your other application&s'

5re you applying for a scholarship to any other institution4
6es -f so0 which4 &o

'ave you previously been awarded a rench .mbassy Scholarship4

6es &o 6ear 7hen4

Application Form Research Internship Pro"ram # (!%

Your Curriculum )itae

*IIth + ,ni-ersity e.aminations ! de"rees

Period !mm/ yyyy" &ame of ,niversity$-nstitution

3ity

Degree

Specialisation

Percentage $ 3%P5

Academic ! Employment record

Period !mm/yyyy" &ame of employer

1rganisation

Position

Pre-ious or present study and stays a/road &includin" France' of at least t0o months1 duration
Period !mm/yyyy" -nstitution 3ity0 3ountry inanced by

French lan"ua"e proficiency

8 &one
D.9 $ D59 e2amination 51

5:

#1

#:

31

3:

-f not D.9 $ D59 0 please specify ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; !school $ coaching classes $ self*taught or any other"

2here did you hear a/out this scholarship3

Professor

Peer $ Senior

3ampus rance

5lliance fran<aise

-f other0 please specify;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;

Application Form Research Internship Pro"ram # 4!%

Statement of Purpose &minimum one pa"e5 ma.imum t0o pa"es in Times Ne0 Roman # $(' Please highlight the reasons for choosing rance and the institution where you will be studying/ Please also e2plain why you would be a worthy candidate for the scholarship .

Application Form Research Internship Pro"ram # 6!%

- hereby declare that the above statements are true to my knowledge and belief= that - am of sound health and not physically handicapped in a way that would prevent me from carrying out my pro(ect in rance/ The rench .mbassy has my permission to electronically store my personal data0 which is re)uired for my scholarship application and my possible stay in rance/ -f a scholarship is awarded to me0 my name and institution of origin may be included in lists published by the rench .mbassy in -ndia/ -f - am awarded a 3harpak scholarship of e2cellence0 - agree to become a >3harpak 5mbassador? of rench higher education when - return to -ndia/ This may involve taking part in one or two higher education events at the 5lliance ran<aise of my city0 or in one or two events organized by a 3ampus rance counsellor in my -ndian university$ institution of origin/

Place @ Date

Signature

Application Form Research Internship Pro"ram # %!%