Application Form for INTERNSHIP Scholarship

Passport size
picture

Please read the guidelines for application before filling the form!

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

First name(s)

Previous surname

Date of Birth (dd.mm.yy) and Place of Birth

Gender

Nationality

Present professional/ studentship position

Highest academic degree

Your field of Study

General field of Study

Specific field of Study

Period for which Scholarship is required (dd.mm.yy-dd.mm.yy)

Number of Months

Institution at which you are currently studying/working

University/Institution
Department/Institute
Address : Street, P.O. Box
Postal code

Tel.

Fax

City

Country

E-mail

Your personal address

Street, P.O. Box
Postal code
Country

Tel.
Ort City/town
E-mail

Application Form Internship Program 1/5

Fax

Your French academic contact and host institution

Title

Surname

First Name
University/Institution
Department/Institute
Street/P.O. Box
Postal code

City

E-mail

Your other application(s)

Are you applying for a scholarship to any other institution?
Yes

No

If so, which?
Have you previously applied for a French Embassy Scholarship?
Yes

No

Have you been awarded a Scholarship?

Year
When?

Application Form Internship Program 2/5

Tel.

Your Curriculum Vitae

X+2 & University examinations / degrees

Period
(mm. yy)

Name of University/Institution

Place

Degrees

Percentage of
marks obtained

Major subject
studied/examined

Academic / Employment record

Period
(mm.yy)

Name of employer

Place

Position

Previous or present study and stays abroad (including France) of at least two months' duration
Period
(mm.yy)

Name of Institution

Place

Country

Financed by

French and English proficiency

Assess your proficiency in reading, writing, listening and speaking the following languages:
1 - excellent, 2 - good, 3 - fair, 4 - sufficient, 5 - insufficient
Reading

Writing

French:
English:
Other:

Application Form Internship Program 3/5

Listening

Speaking

Application Form Internship Program 4/5

Statement of Purpose (minimum one page, maximum two pages in Times New Roman - 12)

Application Form Internship Program 5/5

I hereby declare that the above statements are true to my knowledge & belief, that I am of sound health and not physically handicapped in a
way that would prevent me from carrying out my project in France.
The French Embassy has my permission to electronically store my personal data, which is required for my scholarship application and my
possible stay in France. If a scholarship is awarded to me, my name and institution of origin may be included in lists published by the French
Embassy in India.
If I am awarded a Charpak scholarship of excellence, I agree to become a Charpak Ambassador of French higher education when I return to
India. This may involve taking part in one or two higher education events at the Alliance Franaise of my city, or in one or two events organized
by a Campus France counsellor in my Indian university/ institution of origin.

Application Form Internship Program 6/5

Place & Date

Signature

Application Form Internship Program 7/5