2016-17 Commonwealth Shared Scholarship Scheme: LSHTM Expression of Interest Form
2016-17 COMMONWEALTH SHARED
SCHOLARSHIP SCHEME: LSHTM
EXPRESSION OF INTEREST FORM
This form should be completed by candidates applying for the 2016-17 Commonwealth Shared
Scholarship Scheme (CSSS) at the London School of Hygiene and Tropical Medicine. The details you
provide on this form will be used to check that you are qualified to apply for this funding.
To apply for this funding applicants must have completed and submitted:
1. An LSHTM study application for one of the CSSS-eligible courses with
 Curriculum Vitae
 Two references
 Scanned copies of transcript/s
 Copy of my passport
2. An application using the Commonwealth EAS
3. This Expression of Interest Form with
 proof of English Language proficiency scores (IELTS academic English). Please note that
the School has strict English Language requirements which must be met.
 Curriculum Vitae, showing full details of all periods of study, employment and
unemployment
 scanned copies of your transcript/s, along with any notes explaining grades/levels
Contact Details
Title
First name(s)
Last or Family name
Correspondence
address
Telephone number(s)
Email address
Residence & Nationality Details
Nationality
Country of Permanent
Residence
Country of Domicile
Application/Course Details
LSHTM applicant reference
number
First course choice (as
selected via the LSHTM
application portal) OR the
course you hold an offer for
☐ 2016-17 MSc Public Health (London-based)
☐ 2016-17 MSc Public Health for Development
☐ 2016-17 MSc Public Health for Eye Care
☐ 2016-17 MSc Reproductive and Sexual Health Research
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2016-17 Commonwealth Shared Scholarship Scheme: LSHTM Expression of Interest Form
Qualifications
As these scholarships are very competitive we would expect candidates to have been awarded the
highest grade possible in at least one of their previous degrees.
Please provide details of the course or degree which you are currently undertaking, if applicable.
Qualification
and
full degree title
Institution
attended
Name of
country
if overseas
FROM
month
and
year
FullTO
time
month
or
and
Partyear
time
Anticip
ated
result
Due date
of result
Source of
funding
Self/grant,
etc
Please provide an indication of relevant courses/modules taken and grades received below; or
provide an interim transcript, if available.
Course
Grade
Please provide details of any study (undergraduate, postgraduate and professional) for which you
have already been awarded, starting with the most recent. Please submit a scanned copy of a
transcript for each award, if available.
Qualification
and
full degree title
Institution
attended
Name of
country
if overseas
FROM
month
and
year
FullTO
time
month
or
and
Partyear
time
Result (pass/fail)
Please also indicate
class, division or
percentage
References
Please provide the name and contact details for your two referees.
FIRST REFEREE
Name
Telephone number
Email address
SECOND REFEREE
Name
Telephone number
Email address
2
Source of
funding
self/grant,
etc
2016-17 Commonwealth Shared Scholarship Scheme: LSHTM Expression of Interest Form
Declaration
I confirm that
 I am a national of (or permanently resident in) a developing Commonwealth country, as
listed on the CSSS website.
 I am not currently living or studying in a developed country.
 I have not previously studied in a developed country for one year or more.
 I (or my family) would not otherwise be able to pay for the proposed course of study.
 I intend to return to my home country as soon as the period of study is complete.
 The information I have provided on this form and in the attachments (transcripts, CV, proof
of English) is true, accurate and complete.
If I am successful in gaining a scholarship
 I give consent for the School and its scholarship partners to announce my name and the
award, and to use photographic images of me, in their publications and websites. I also
consent to write a 250 word student profile for use in publications.
 I consent to my application forms, transcripts and references being released to the
scholarship subpanel.
Signature ______________________________________________________________
Date ___________________
Please hand-sign this form or attach an electronic signature. Typed signatures will not be accepted.
Please note that your application will not be processed if it is incomplete.
Please return by email to: scholarships@lshtm.ac.uk by 1 March 2016.
Registry, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT
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