APPLICATION FORM FOR EANO FELLOWSHIP

Please complete all parts (A-H) of this form.
Before filling in the application, please read the conditions of the EANO Fellowship program. Concerning the age limit, no exceptions can be made.

I have read the conditions of the program: * YES NO

Family name (as in your passport) *

Address *

City *

Postal Code *

Country * AfghanistanÅlandAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo-BrazzavilleCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroesFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SAR of ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR of ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern MarianasNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSão Tomé e PríncipeSaudi ArabiaSenegalSerbiaSerbia and MontenegroSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandThe BahamasTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUS Virgin IslandsUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabwe

Phone *

Cell

E-Mail *

Title * Mr. Mrs. Miss Ms. Dr. Prof.

Sex * Male Female

Place of birth *

Date of birth: *

Where are you currently working ? *

If you are currently working, please provide details of your function, grade and main responsibilities. (Maximum 250 characters)

Attachments (as mentioned in the general terms and conditions, under 10, 11 and 12):

• PDF passport
• PDF Recommendation head of your department/institute
• PDF Letter of acceptance of institute where the project will be performed (head)
• A short description (no more than one page, A4) of the institute/department in which the applicant will perform his/her project
• Project description This project description contains at least the following items
  • Title of the project
  • Summary of the project (no more than 2 pages, A4)
  • Introduction and rationale
  • Methods
  • Expected results
  • Scientific value
• Photocopies (preferably PDF's) of all relevant academic diploma's, certificates or transcripts, with accompanying certified translations into English if they are in another language
• References (no more than 50)
• Milestones
• Financial plan for the project (please note that the sum of the fellowship can not be exceeded)
• A recent version of the curriculum vitae of the applicant

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(as one ZIP-File) Please note: you can go back to any part after step H