PAN AFRICA CHEMISTRY NETWORK
Scholarship Application Form
Copyright © 2009 Pan Africa Chemistry Network
APPLICATION FORM
PACN- Fellowships and Scholarships
Name:
Home Address:
Telephone:
Fax:
Email:
Home Institution Address:
Telephone:
Fax:
Email:
Website (if any):
Your CV:[Please supply a brief CV detailing your education, employment and area of research interest]
Part 2: Type of Application (Tick only one)
Part 1: The Applicant
PACN Africa-UK Exchange Scholarships
PACN-Syngenta Visiting Research Fellowship
PACN-Africa-Brazil Exchange Scholarships
Maximum Duration: 2 weeks
Maximum Duration: 2 weeks
Maximum Duration: 2 weeks
Part 3: Work Programme
Work Programme Title:
Start Date:
End Date:
Details of Work Programme (WP)
A comprehensive description of the WP, not more than 2 pages, including the aims, objectives, details of the WP, deliverables, reports and plan for dissemination & application of the research findings [The box will expand as you type]
Specify currency [GB£, US$]:
Part 4: Budget
Travel from Africa to Host Institution:
Board & Lodging in Host Institution:
Subsistence in Host Institution:
Consumables:
Other costs (specify):
TOTAL:
Please supply contact details for the following referees:
Part 5: References
1. A senior member of your Home Institution
Name:
Address:
Telephone:
Fax:
Email:
Independent Referee 1;
Name:
Independent Referee 2;
Name:
Address:
Telephone:
Fax:
Email:
Address:
Telephone:
Fax:
Email:
Part 6: Publications (Give details of your published work [The box will expand as you type)
herein apply for PACN Africa-UK Exchange Scholarship/PACN-Syngenta Visiting Research Fellowship.
I understand that any mis-statement shall render me ineligible.
CLICK HERE TO DOWNLOAD A PFD FORMAT OF THE FORM