<p> Application for a Leibniz - DAAD Research Fellowship 2015</p><p>Name</p><p>Nationality</p><p>Chosen Leibniz Institute</p><p>Leibniz-DAAD-Research Fellowship Application Form Page 1 2</p><p>1. Personal Data</p><p>Surname Please use the name exactly as stated in your passport, underline main name</p><p>Academic title</p><p>First name(s)</p><p>Date of birth</p><p>Place of birth</p><p>Country of birth</p><p>Country of residence</p><p>Gender male female</p><p>Marital status married single</p><p>Number of children</p><p>Present occupation </p><p>Present employer</p><p>2. Contact Data </p><p>Email</p><p>Street</p><p>Post code, town</p><p>County/state </p><p>Country</p><p>Fax</p><p>Phone</p><p>3. Secondary School Education</p><p>Duration and location fro to in m</p><p>Type of final exam (certificate title)</p><p>Date of award</p><p>Leibniz-DAAD-Research Fellowship Application Form Page 2 3</p><p>4. Higher Education and Academic Degrees</p><p>Academic Major Subject University/ Town Country Duration Result Date Degree (%, A-D) of result Bachelor</p><p>Master</p><p>Ph.D.</p><p>Other degree</p><p>Expected degrees Date within the following Degree (dd/mm/yyyy months Title )</p><p>5. Language Skills</p><p>Language Years of learning Very good Good Fair Poor English German</p><p>6. Previous visits abroad for study / research / work </p><p>Country Town Institution Goal From To Germany</p><p>7. Practical / professional work experience</p><p>Country Town Institution Goal From To</p><p>8. Previous Scholarships</p><p>Country Organisation Host Institution Goal From To Germany DAAD</p><p>Leibniz-DAAD-Research Fellowship Application Form Page 3 4</p><p>9. Envisaged Academic / Professional Career</p><p>10. Social Engagement / Extracurricular Activities</p><p>11. Other Information / Remarks</p><p>12. Name and address of person to be notified in case of emergency</p><p>E-mail</p><p>Street</p><p>Postcode</p><p>Town/Suburb</p><p>State/County/Province</p><p>Country</p><p>Phone/ FAX</p><p>The completed application form must be accompanied by the following documents (in English):</p><p> curriculum vitae;  list of publications (if any);  description of the research project (max. 3 pages);  detailed work plan and schedule (max. 1 page);  abstract of the doctoral thesis (max. 3 pages);  two letters of recommendation, which should be written by scholars of the applicant’s own choice and must be enclosed in sealed envelopes or sent by the referees directly to the DAAD head office in Bonn by the closing date for applications;  copies of all academic degree certificates and transcripts of records with certified translations into English or German;</p><p>Leibniz-DAAD-Research Fellowship Application Form Page 4 5</p><p> English language certificate (e.g. TOEFL, IELTS) or confirmation of the English language skills by a university teacher of the applicant´s own choice. The application and accompanying documents will remain with the DAAD. Personal data will be stored in the DAAD’s computer files only to the extent necessary for administration of applications and fellowships and in compliance with the “Federal Data Protections Act“. Data will be provided to the respective Leibniz Institute which will be included in the decision making process.</p><p>Applicant‘s declaration:</p><p>I certify that the information in this application is accurate to the best of my knowledge. Furthermore I agree to inform the DAAD immediately of changes and amendments. I have taken note of the information provided regarding this application as well as the notice about the storage of personal data. I accept responsibility for my completed application. I agree that this application and accompanying documents shall remain with the DAAD. I agree that the DAAD will forward the documents and the personal details to the Leibniz Association and its relevant institutions, which take the final decision. Neither the DAAD, nor the Leibniz Association nor the Leibniz Institutions will pass on the details to third parties.</p><p>Place Date Signature</p><p>Leibniz-DAAD-Research Fellowship Application Form Page 5</p>