JUNIOR RESEARCH FELLOWSHIP PROGRAM

APPLICATION FORM2011

Application must be sent by post (in duplicate with the supporting documents) to:

French Embassy – SCAC - CSU29 Sathorn Tai Road, Bangkok 10120

APPLICATION TO BE SUBMITTED BEFORE: March 13th, 2011

IDENTIFICATION

Mrs Ms Mr Single Married Other

Surname : Name :

Date of Birth : Place of birth :

Nationality (specify in case of dual nationality): THAI

CONTACT DETAILS (to be filled in CAPS LETTERS) *

Home Address :

City/Town :

Home Phone :

Work Phone :

Mobile Phone :

E-mail Address :

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Reserved for SCAC:Application submitted on:

File n°: 2011/Field :

HOSTING LABORATORY

Name of the Lab and/or Institution:

Address :

Details of the senior researcher in charge of hosting the candidate in France (Name, E-mail, phone number):

INTENDED RESEARCH PROJECT IN FRANCE

Field of study :

Subject :

Title of the project :

Length of stay :

Intended departure date (DD/MM/2011):

WORK EXPERIENCE OR INTERNSHIPS

Period Company Position

FOREIGN LANGUAGE LEVEL:Junior Research Fellowship Program 2011 Page 2/4

ENGLISHLevel: If applicable, certificate (TOEFL, TOEIC, IELTS,… ): Year:

FRENCHLevel: If applicable, certificate (DEFL, DAFL, TCF,…): Year:

Previous stay in France: No Yes, specify the reason:

ENGAGEMENT OF THE APPLICANT

I, the undersigned (surname, name) ………………………………………………..

certify that the above information is complete and correct to my best knowledge

certify that I will gather all efforts to complete successfully the research project described

commit myself to work regularly in the hosting research lab in France for the whole term of

the grant awarded

Date : Signature :

AGREEMENT FROM THE RESPONSIBLE AUTHORITY I, the undersigned (surname, name, title) ……………………………………………..

……………………………………………………………………………………………………….

Authorize ………………………………………………………. to leave for France

for a duration of ........... months, if he/she is selected within this junior research fellowship

program.

Date:

Signature :

SUPPORTING DOCUMENTS REQUIRED AND CHECK LIST Documents to be provided, in French or in English:

Filled and signed application form Passport Photocopy Up-to-date résumé stating the entire curriculum (including publications) Cover letter explaining motivations and interests in the project Copies of academic diploma Detailed description of the research project Letter from the hosting laboratory in France

Optional documents : Academic and/or professional recommendations

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Language proficiency certificates: French (TCF, DELF, DALF, academic degree,…) and/or English (TOEFL, TOEIC, etc.)

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