<p>AJF Use </p><p>Received on</p><p>Ref. No. Award </p><p>Application Form – Al Jalila Foundation International Scholarship Program</p><p>Harvard Medical School – Master of Medical Sciences in Global Health Delivery (MMSc-GHD)</p><p>Applicant’s personal details</p><p>Full name: Gender: Date of birth: Marital status: Emirate of residency: UAE passport number: UAE nationality document (Khulasat AlQayd) Number: UAE ID number:</p><p>Contact details</p><p>Mobile:</p><p>E-mail:</p><p>PO. Box & Emirate:</p><p>Full home address:</p><p>Page 1 of 8 Scholarship for postgraduate program you are applying for</p><p>Academic Institution Official acceptance yes no Country and City Program start date (month/year) Program Duration of study (in years)  Master PhD AJF Use </p><p>Received on</p><p>Ref. No. Award </p><p>Education/training, and professional body membership (most recent first)</p><p>AGPA or Country Date Degree (if University/Institution Specialty/Area percentage (m/y) applicable) (if applicable)</p><p>Details of Current Employment (If Applicable):</p><p>Title of current position:</p><p>Organization:</p><p>Start date of your current employment:</p><p>End date of employment contract (if applicable):</p><p>Basic salary: </p><p>Total Salary (basic and allowances):</p><p>If salary is funded from more than one source, please specify the other sources: </p><p>Page 3 of 8 Would you be able to obtain a paid study leave from your employer for the proposed study Yes No period?</p><p>If yes, your salary from your employer will be paid Full Basic in (Full/Basic) during your study leave?</p><p>If you did not obtain a study leave for the proposed study period, how would you proceed with your study?</p><p>Complete Employment History (Most Recent First):</p><p>Date Date Position Department Organization from to Country </p><p>Clinical Status (if applicable)</p><p>Are you clinically trained? Yes No</p><p>Are you clinically active? Yes No</p><p>What is your specialty? AJF Use </p><p>Received on</p><p>Ref. No. Award </p><p>Summary of your academic/clinical/ career achievements and awards to date, including key achievements, prizes (state year of award) and any previous research experience (no more than 250 words. Calibri style, font size 12).</p><p>Please list all your publications, including original research publications and other scholarly contributions (if applicable). Publications should be in chronological order with the most recent first. Please give citation in full, including title of paper and all authors.</p><p>Page 5 of 8 Please explain why you wish to pursue a Master of Medical Sciences degree in Global Health Delivery (MMSc-GHD) at Harvard Medical School and elaborate how this will further your career (no more than 500 words, Calibri style, font size 12).</p><p>Referees </p><p>Briefly indicate how Name Occupation Organization Telephone Email you know this person</p><p>Please provide all of the following documents to complete your application: AJF Use </p><p>Received on</p><p>Ref. No. Award </p><p>1) Completed AJF international scholarship application form </p><p>2) Curriculum Vitae</p><p>3) Copy of Emirates ID</p><p>4) Copy of passport</p><p>5) Copy of UAE nationality document (Khulasat AlQayd)</p><p>6) Copy of latest relevant academic degree (if obtained from a private academic institution, a copy of the attested degree is required)</p><p>7) Evidence of successful application for the postgraduate international program. </p><p>8) Academic acceptance letter from the international academic institution, he/she must submit the letter to Al Jalila Foundation.</p><p>9) Official Academic Transcripts (with AGPA score on a 4.00 scale)</p><p>10) TOEFL/ IELTS certificate</p><p>11) Two Recommendation letters. If applicant is/was employed, preferably at least one letter from current/previous employer</p><p>12) Study leave letter from current employer outlining if the study leave is paid or unpaid, type of leave, and duration of leave (if the applicant is currently employed)</p><p>Note: Applicant must submit to Al Jalila Foundation documents number (1) and (7) by November 30, 2016, and the rest of the documents by January 7, 2017.</p><p>Page 7 of 8 Signature (Applicant): ______Date of Submission: ______For inquiries, please email us on [email protected] </p>