Hitachi Future Leaders Fellowship Program Application Form

Hitachi-DST Scholarship Programme for South African Engineers Application Form 1. Personal Information

Attach a recent Name: photograph of title last or family first or given middle yourself (taken in the last six months) Date and Place of Birth:

day / month / year place (size 4cn×3cm)

Sex: ( ) Male Marital Status: ( ) Married ( ) Female ( ) Single

Nationality:

Home Address:

Telephone: Fax: Email:

2. Professional Information

Company:

Section:

Position: Specialization:

Work Address:

Telephone: Fax: Email:

Professional History Month/Year Employer Section/Title Nature of Work

1/3 3. Academic History

List in chronological order schools attended after high school level. Year Entered Year Graduated Institution Fields of Study

List in chronological order any scholarships and awards you have received in the past. Year Name of Scholarship & Awards Description

4. Comments on what you would like to achieve through this scholarship programme if selected : (Please use Appendix C if you need more space to write)

I hereby declare that the above statement is true and correct.

Date: Signature:

Please attach the following documents to this form:  One (1) abstract of a project you have experienced in your engineering field (approximately 2,000 words) (Appendix-A)  One (1) letter of reference written and signed by a representative of your company in the provided format (Appendix-B)

2/3  Comments on what you would like to achieve through this programme (Appendix-C) You will also be requested to give a ten-minute presentation on your engineering field during the final interview for selection.

Please note that if you pass final selection, you will then be required to submit the following items.  A medical certificate signed by a doctor in the format, prescribed by The Association For Overseas Technical Scholarship (hereinafter referred to as “AOTS”)  Documents required to obtain visa: “Personal Record and Training Contract” in the format prescribed by AOTS, and a photocopy of your passport  An “Overseas Travel Insurance Consent Form” in the format prescribed by AOTS