<p> Hitachi-DST Scholarship Programme for South African Engineers Application Form 1. Personal Information</p><p>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: </p><p> day / month / year place (size 4cn×3cm)</p><p>Sex: ( ) Male Marital Status: ( ) Married ( ) Female ( ) Single</p><p>Nationality: </p><p>Home Address: </p><p>Telephone: Fax: Email: </p><p>2. Professional Information</p><p>Company: </p><p>Section: </p><p>Position: Specialization: </p><p>Work Address: </p><p>Telephone: Fax: Email: </p><p>Professional History Month/Year Employer Section/Title Nature of Work</p><p>1/3 3. Academic History </p><p>List in chronological order schools attended after high school level. Year Entered Year Graduated Institution Fields of Study</p><p>List in chronological order any scholarships and awards you have received in the past. Year Name of Scholarship & Awards Description</p><p>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)</p><p>I hereby declare that the above statement is true and correct.</p><p>Date: Signature: </p><p>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)</p><p>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. </p><p>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</p><p>3/3</p>