Unesco Inter-University Post-Graduate Course in Biotechnology

Annex 2

UNESCO BIOTECHNOLOGY SCHOOL IN ASIA 2014

Application for Admission Paste your passport photograph taken within the past 6 months.

Photo (4 x 6 cm) Please write in English, and type or print in block letter. Proper nouns/unique nouns should be written in full, and not be abbreviated.

Date: (Year) (Month) (Day)

Name in full: □Male Gender: Family name First name Middle name □Female

Name in Chinese character, if available.

Marital status Date of birth Age (as of August 2014) Nationality □Single Year Month Day □Married Mailing address (Current address)

Postal code

Telephone Country Code Area Code Local No. Ext. Facsimile e-mail address Present status, with the name of university (Faculty and Department) attending, or of employer Name of the international airport in your country to depart to Indonesia/Thailand/Viet Nam

Address of nearest Japanese embassy to get your Japanese visa

Name: Application form (Category a) 1/6 Academic Background Period of Degree or Required Name and address of school attendance diploma years of (month/year) awarded schooling From: Years Elementary education or To: Elementary school

From: Years Secondary education or To: Lower secondary school

From: Years

Upper secondary school To:

Higher education From: Years Undergraduate level (Department, Faculty To: and University) From: Years Postgraduate level (Department, Faculty, To: and University)

Years Total years of schooling mentioned above

G.P.A. in your university* (Both at undergraduate level and post-graduate level). such as 3.5/4.0 (full score) Your Maximum Period of attendance Name of school G.P.A. G.P.A. score (month/year) score in school From Undergraduate To

From Postgraduate To

*Application will be effective only if academic transcript is attached. Name: Application form (Category a) 2/6 Employment Record (Begin with the most recent employment, if applicable)

Period of Name and address of organization Position Type of work employment

Language Proficiency (Evaluate your level and fill in with an X where appropriate)

Excellent Good Poor

English

Bahasa Indonesia

Vietnamese

Language Qualification (TOEFL, TOEIC, IELTS or others)

Name of the test

Year Month Day Date of the test Score/Classification

Name of the test

Year Month Day Date of the test Score/Classification

Family Background

Name: Application form (Category a) 3/6 Name Relationship Age Occupation Name of organization

Person to be notified, in case of emergency

Name in full Family name First name Middle name

Postal address

Telephone

Facsimile e-mail address

Relationship

Occupation

Immigration records to Japan/Indonesia/Thailand/or Vietnam Date Purpose From To From To From To From To University and Country Choice of the University Country university and country to enroll Name: Application form (Category a) 4/6 1

2 into the relevant 3 master course

Indonesia (Gadjah Mada U or Bandung Institute of Technology); Thailand (King Mongkut's U Technology Thonburi (KMUTT), or Mahidol U); Vietnam (VN National U Hanoi, or VN National U Ho- Chi Minh City)

Research Background

Thesis title for undergraduate study

Thesis title for postgraduate study (if applicable) List of research achievements List your research publications, item by item, stating author names, title of the publication, publication year, journal or book name, volume, pages (from start to end).

References (List two individuals who are familiar with your personality and ability, one of whom should be the applicant’s supervisor. One of the references, preferably and where possible, may be an alumnus of the previous UNESCO Postgraduate University Course in Microbiology and Biotechnology.) Name: Application form (Category a) 5/6 Name Position Affiliation and address

Describe briefly your prospects for work/research in your home country after finishing the Course

Certification

I certify that the foregoing statements are true and complete to the best of my knowledge and belief, and understand that any willfully false statement is sufficient cause for rejection of the application, or if I have been admitted to the UNESCO Biotechnology School in Asia, for the dismissal from the Course.

Date: Signature of applicant:

Date: Signature of supervisor:

Name: Application form (Category a) 6/6