Application Form s41

University of Fudan – University of Queensland Biomedical Sciences Summer Research Scholarship Program

APPLICATION FORM Please complete all sections of this form Postgraduate Administration Officer in English and return with the items in the UQ Diamantina Institute, The University of Queensland Application Checklist to: Email: [email protected]

1 Personal Details Title Mr Ms Miss Mrs Other Family name/s Given name/s

Date of Birth / / Gender Male Female Address

Email Telephone / Mobile

2 Academic / Professional Profile University Degree Major Commencement Year Current GPA Expected Completion Year Area of research interest – provide details separately if you require more space to complete this question

Details of relevant employment/training/internship experience – provide details separately if you require more space to complete this question

Please outline your future research plans – provide details separately if you require more space to complete this question

3 Homestay Profile

Do you smoke? No Yes How many cigarettes each day? (if you smoke, you may still be placed in a non-smoking home) Do you like pets such as dogs and Do you like children? No Yes No Yes cats? Do you have any special dietary needs (e.g. vegetarian)? No Yes Details

Do you have any allergies? No Yes Details Do you take any medication, have a medical condition or No Yes disability? Details Religion (if any) Please describe your family and include something special about yourself, your hobbies and interests, to help match you with a suitable host family.

4 Application Checklist A scanned copy of your recent English language test results (eg: IELTS/TOEFL/Michigan etc)

A scanned copy of your academic transcript

A scanned copy of the picture/information page of your passport

A scanned copy of your CV

5 Privacy Declaration By submitting this form I agree that ICTE-UQ can share the information provided by me, as well as information about my course attendance, results and progress with my university or college, my sponsor or educational representative and relevant parties involved in program management and delivery. I also understand that a copy of this form will be provided to my appointed homestay family.