HKU-Pasteur Research Centre Limited

The information provided will be used for admission to HKU-PRC Courses. If you are admitted to the course, this form will be filed Ref No.: - for reference. It will be accessible only to For Office Use those responsible for processing your application, or for administrative and academic aspects of your candidature. Under Date Received: the Personal Data (Privacy) Ordinance, applicants have rights to request access to and/or correction of their personal data held Acknowledge: by the Centre. Requests should be made to the CEO & Scientific Director, HKU-Pasteur HKU-Pasteur Research Centre Limited Research Centre Limited (email: hku- [email protected]). If your application is unsuccessful, this form will be destroyed. COURSE APPLICATION FORM

Please read the following notes before competing this form: 1. Applicants are advised to provide all the information requested in the form, where applicable, failing which the Centre may not be able to process and consider your application. 2. Please send the completed form together with letter(s) of recommendation from referees by e-mail to hku- [email protected], the CEO & Scientific Director, HKU-Pasteur Research Centre Limited, Hong Kong. Letter of reference may be sent separately by the referees to [email protected].

1. COURSE:

Title of Course

Have you participated in our courses before? Yes Pls specify: Virology Course Cell Biology Course No Immunology Course Others:

How did you learn about this course?

2. PERSONAL INFORMATION: Present Position: Post-doc PhD student Mphil student other (pls specify) Surname: Given name (in full): Date of birth: Gender: Female Male HKU - UNo (if any): Nationality: Correspondence Address:

Contact telephone no: Email address:

3. YOUR CURRENT SITUATION: Institute: Department: Country: Subject of Current Research: Current Research Project(s) Title: Start Date: Expected Date of Termination: Research Director(s)/Supervisor(s): Language of Instruction: English Chinese French other, pls specify: 4. ACADEMIC QUALIFICATIONS: (most recent first) 1. Title of Degree: Date Obtained: Major Subject: Honours/Grade (if applicable): Institution: Country: Language of Instruction: English Chinese French other, pls specify: 2. Title of Degree: Date Obtained: Major Subject: Honours/Grade (if applicable): Institution: Country: Language of Instruction: English Chinese French other, pls specify: 3. Title of Degree: Date Obtained: Major Subject: Honours/Grade (if applicable): Institution: Country: Language of Instruction: English Chinese French other, pls specify:

5. AWARDS AND HONOURS: Type of Award Awarding Institution Date of Award

6. RESEARCH & LABORATORY EXPERIENCE IN ACADEMIC OR PRIVATE RESARCH INSTITUTE / COMPANY: Company/ Position / Employment Period Topic Institution Staff Grade Mode From To Full-time Part-time Month / Year Month / Year Full-time Part-time Month / Year Month / Year Full-time Part-time Month / Year Month / Year Full-time Part-time Month / Year Month / Year 7. CAREER OBJECTIVES: Fundamental Research (Academic)

Clinical Research

Teaching

Applied Research/Biotechnology (Private Company/Industry)

Others:

8. GENERAL OUTLINE OF CURRENT RESEARCH PROJECT: (Limit to 200 words; do not give confidential information, e.g. unpublished results.)

9. WHAT DO YOU EXPECT FROM THIS COURSE? (Limit to 200 Words)

10. LIST OF PUBLICATIONS INDEXED IN PUBMED: (Limit to 5 most relevant publications) 1. 2. 3. 4. 5. 11. CONFERENCE PRESENTATIONS: (Limit to 5 most relevant; Indicate whether oral or poster session) 1. 2. 3. 4. 5.

12. ENGLISH LANGUAGE PROFICIENCY TEST: (For applicants from institutions outside Hong Kong where the language of instruction and examination is not entirely in English.) DATE OF TEST SCORE TOEFL TWE/Essay Rating IELTS Others

13. REFERENCE LETTERS: (The applicant should arrange for 2 reference letters, including current supervisor, to be sent separately to [email protected]. Please list below the names of the 2 referees. )

Name Name Position Position Organization Organization E-mail E-mail

I declare that the information I have given in this application is correct and complete to the best of my knowledge and belief. I agree that HKU-Pasteur Research Centre Limited may conduct a reference check by contacting my present/prior supervisor(s) and or institution(s) where I received my education.

Date: Signature: