Scholarship Application Form s3

SCHOLARSHIP APPLICATION FORM For scholarships managed and awarded by the Master HDFS If you request a scholarship when applying to the Master in Human Development and Food Security (hereafter the Master), in order to fully or partially waive the Master Tuition fee of euro 6,000, you must send this form (with the required annexes) together with your application form. All documents must be sent to the Admission Office by May 31st, 2014.

Student Legal surname: ...... First name(s): ...... (in capital letters) Date and Place of birth: ......

1. PERSONAL INFORMATION

1.1. Brothers and sisters dependent on the parents Legal surname and first name(s) Date of birth School / Class Home address

1.2. Student’s spouse Legal surname: ...... First name(s): ...... Spouse’s maiden surname:...... Occupation: ...... Unemployed□ Part-time □ Full-time □

1.3. Student’s child(ren) Legal surname and first name(s) Date of birth School / Class Home address

2. FINANCIAL INFORMATION

SCHOLARSHIP APPLICATION FORM (Master HDFS 2014-2015) 1 2.1. Family income Annual gross income Gross Wealth Employer (Name and address)

Father

Mother

Spouse

Foster / Step family

Other (person you live with, guarant- or)

2.2. Personal income Income (current situation)

Gross salary

Small jobs

Savings

Spouse’s gross income

Contributions from parents, others

Maintenance allowance

Family or unemployment allowances, old-age pension, invalidity insurance

Health insurance subsidy

Scholarships :

- Private funds

- Other

Other resources

2.3. Request for financial assistance Have you submitted any other application for financial assistance? no □ yes □ Organisation contacted ...... Date ......

SCHOLARSHIP APPLICATION FORM (Master HDFS 2014-2015) 2 2.4. Exemption Have you already benefited from tuition fee exemption? no □ yes □ I do commit myself to return to my country of origin after my studies and shall therefore not be eligible for an extension of visa. no □ yes □ ......

3. KINDS OF SCOLARSHIPS (you can select more than one) I wish to apply for: Tutor scholarship □ Full scholarship □

4. DOCUMENTS TO BE ATTACHED TO THE APPLICATION FORM - Proof of income and family wealth (tax certificates, scholarship award decisions, etc.) - Letter stating the reasons for your application

5. STUDENT’S DECLARATION I certify that the statements made above are accurate (any false statement will entail the cancellation of the application) and authorize officials of the Master at the University of Roma Tre to conduct with the concerned authorities the required verifications to examine my situation with regard to income and studies.

Should I be awarded a scholarship, I commit myself to adhere to the rules by signing a scholarship contract.

Rome, date ...... Signature: ......

Your data will be handled strictly confidentially

 The full and partial scholarships are intended for outstanding students from countries with a low and medium Human Development In- dex (as defined by the UNDP) under the condition that they commit themselves to return to their country at the end of their course of studies so that their fellow countrymen may benefit from their training.

SCHOLARSHIP APPLICATION FORM (Master HDFS 2014-2015) 3