Please read the USM Global Fellowship Application Guidelines at www.ips.usm before competing this form A. GENERAL INFORMATION Please remember to attach a photo of yourself and copy of your passport (if any) / ID. Please provide your name exactly as they are indicated in your passport/IC Name: I/D / Passport No (If any):
Mailing Address:
Passport’s date and place issued: Passport Expiry date: Nationality: Date of birth:
Age:
E-mail:
Contact Number:
B. ACADEMIC / PROFESSIONAL INFORMATION Higher Education : Please enclose copies of all degrees awarded and university-issued transcripts No secondary education certificates are needed nor any certificates of participation in conferences or training courses Degree awarded (e.g)
Year
Programme
CGPA/Class/Gr ade/Percentag e
Programme Mode (coursework/mixed mode/research)
University
C. ENGLISH LANGUAGE SKILLS (Please attach proof) TOEF/IELTS
BAND/SCORE
DATE TAKEN
D. RESEARCH DETAILS FOR PHD STUDY Indicate area of proposed research/study for PhD : Indicate planned research title for PhD (please attach detailed research proposal) :
E. ACADEMIC/PROFESSIONAL EMPLOYMENT Organisation (Employer)
From
To
Position
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F. INVOLVEMENT/EXPERIENCE IN ACADEMIC & NON-ACADEMIC ACTIVITIES Activity
Position (e.g participant/organiser)
Date
G. PUBLICATION ACTIVITIES Indicate your publications details in journals. Please indicate details and proof where needed Articles Published (reference format)
ISI/Scopus Listings/Others
Impact factor
H. RESEARCH EXPERIENCE Indicate your previous experience in research Research undertaken
Institution & Country
Date
I. REFEREES : Indicate names address and contact details of a senior researcher/supervisor familiar with applicant’s work; their reference letter must be letter-headed, signed and submitted to USM. There is no standard format. If sent by email, it should be a scanned copy. The letter can be submitted either by the referee of by the applicant directly with this form. Name: Organisation: Contact Number:
Fax:
E-mail:
Relationship to candidate:
Applicant’s acceptance of conditions governing the USM Global Fellowship I, the undersigned, declare that the particulars given by me in this form are correct. I understand that the funding can be withdrawn if any information given in this form is found to be inaccurate. I have read and understood the conditions of the USM Global Fellowship as stated. Applicant's Signature
Date
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ENCLOSURES CHECKLIST Important ; Please ensure that ALL relevant enclosures are included with the completed application form Please only submit the material requested as any other material not listed is not required (e.g secondary education certificates, certificates of participation in conference or training courses etc) Passport size photograph A copy of passport (if any) for non Malaysian applicant or ID. Only the first page with personal details is required Research Proposal Proof of publication in journals (provide link if available on website) Certified copies of University degree certificates and relevant university transcripts for all academic degrees Certified copy of IELTS/TOEFL 9if any) Certificate of good health from a qualified medical doctor OTHER INFORMATION How did you find out about USM Global Fellowship? Institute of Postgraduate Studies, Universiti Sains Malaysia’s website Word of mouth/email from colleague Newspaper Recommendation of supervisor Postgraduate Exhibitions / Student Recruitment Activities Postgraduate Talks / Seminars Others (please specify)
SUBMISSION GUIDELINES For submission of application by courier
Dean, Institute of Postgraduate Studies Universiti Sains Malaysia 11800 USM, Penang MALAYSIA Fax: +604-653 2940
For submission of application by e-mail
Please save the completed application form as an MS Word document with both your name and the Fellowship’s acronym in its file name. Example: If your name is Ahmed Abu, name the file “AHMED_USMGF.doc” as appropriate. All proof and documents should be scanned and compressed together with this application form in a zipped file to avoid your documents to be missed out. Please e-mail to
[email protected]
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