GLOBAL
PLATAFORM 4
SYRIAN
STUDENTS
EMERGENCY
ACADEMIC
SUPPORT
APPLICATION FORM FOR EMERGENCY ACADEMIC ASSISTANCE:
Scholarships and Grants (2013-2014 Academic Year)
APPLICATION ref. No. ____________
DEADLINE FOR SUBMISSION: 15 SEPTEMBER 2013
Instructions: Parts I, II, III and IV of the application should be completed by the
candidate in capital letters. When there are several options, please kindly choose
only one.
PART I – GENERAL
1. APPLICATION FORM FOR: ___________________(Portugal or Lithuania)
2. Family Name
_____________________
First Name
_________________________
Other Name
_____________________
1
3. Age, Date and Place of Birth
AGE:
_____________________________(Country)___________________(Town or village)
_________(Day) __________ (Month) _______________(Year).
4. Male ________________ or Female _________________
5. Nationality or country of Origin : SYRIA
6. Marital Status ____________________(single, married, divorced, widowed)
7. Religion ____________________(optional)
8. Disability /Special needs : Please indicate whether you have a disability or
special needs :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9. Date of entry in present country of asylum (if applicable):
__________(Day)______________(Month) _____________(Year)
10. Present address:
TOWN:___________________________________________________________
ADDRESS:________________________________________________________
_________________________________________________________________
2
11. Countries in which applicant has resided since she/he left SYRIA:
COUNTRY
From (Day, Month, Year):
To (Day, Month, Year):
_______________________
____________________
______________________ _______________________
12. Name of applicant’s father :
_______________________________________________________
13. Dependants : please provide names and addresses of spouse, husband,
children and/or other dependants
Name
Relationship
Age
Place of birth
Country (present
residence)
14. Should a scholarship be awarded, what arrangements will be made by the
applicant to ensure the subsistence of his/her family during his/her studies ?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
3
PART II – PREVIOUS EDUCATION
Instructions: applicants should attach photocopies of certificates and/or other
documentation. If not available, please indicate under item 20 where examinations
were taken, name of examining board, grade obtained and if possible any existing
academic references you may. You can add any additional information you feel
supports your application
15. University/Institution: please provide name, location, period and field of
study, and degree or other academic distinctions obtained.
Name, City, Country From
To
Main course of study
Degree
obtained
16. Schools and other formal training or education: please provide details of
primary, junior and senior secondary school, technical school or
apprenticeships
Name, City,
Country, Type
From
To
Course of study
Degree
obtained
4
17. Languages: please rate as E=Excellent; G= Good, and F=Fair
Mother tongue
Read
Write
Other Languages:
Speak
Do you have any recognized
certificate of proficiency ? Please
specify.
18. Previous employment experience: please list all professional experience,
beginning with the most recent:
From
To
Details
19. Previous civic experience – work with community, international non formal
education experiences etc
From
To
Details
5
20. Please attach to your form a copy of relevant certificates and/or other
documentation.
If they are not available, please attach any additional information you feel
supports your application and indicate:
a.) Where did you take your examinations?____________________________
_____________________________________________________________
b.) Date:________________________________________________________
c.) Name of the examining board?___________________________________
_____________________________________________________________
d.) Grade obtained:________________________________________________
e.) Names and titles of academic references:
1.____________________________________________________________
2.____________________________________________________________
3.___________________________________________________________
f.) Any other relevant information:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
PART III – PLANNED EDUCATION
21. A). Proposed field of study: please provide a detailed and precise description
of subjects to be studied - :
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
B) Please justify your choice
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
6
____________________________________________________________________
____________________________________________________________________
22. Level of degree studying for (eg BA, MA etc)____________________________
23. Length of time required to complete programme of study :
_________________________________________________________________
_________________________________________________________________
24. Proposed country of study:
________________________________
25. a). Has the applicant received a scholarship previously ?
___________________________(Yes or No)
b). If so, please provide details
____________________________________________________________________
____________________________________________________________________
26. Has the applicant taken steps to obtain a scholarship through another
channel ?
a). ______(Yes or No)
b).If so, please provide details
____________________________________________________________________
____________________________________________________________________
27. Has the applicant requested admission to a Higher Education Institution?
______(Yes or No)
b). If so, please indicate the name and the country
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
28. Has the applicant been admitted to a Higher Education Institution ?
a). ______(Yes or No)
7
b). If so, please indicate name and country
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
29. If you are admitted, would you think it will be important to have the
opportunity to attend a training course on intercultural dialogue,
understanding, peace building and reconciliation ?
a). ______(Yes or No)
b). If so, please give three good reasons for your choice
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
30. If you are admitted, would you be ready to make a commitment to
actively participating in such a course ?
______(Yes or No)
PART IV – FINANCING NEEDS
31. Type of assistance requested: please itemize (ie school fees, maintenance,
books)
ITEM
YES or NO
Tuition fees/year
8
Accommodation/month
Meals/month
Study-related
allowance/month
Travel
TOTAL estimated cost in local
currency
32. a). Contribution from other funding sources towards above cost:
SOURCE
AMOUNT
32.b). Amount requested from the Global Platform:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
33. Remarks
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------9
I certify that my statements in response to the foregoing questions are true,
complete and accurate to the best of my knowledge and belief and I understand that
false information given in this application will affect my chances of selection and
continued scholarship.
Place and date_____________________________
Signature of applicant ______________________
Goof luck!
10
PART V- OTHER POINTS (to be completed by Global Platform and other partners)
DO NOT WRITE ANYTHING BELOW
31. ACADEMIC ISSUES
a) Preliminary assessment:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
b) Academic profile:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
c) Host University/Higher School assessment:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
32. LEGAL AND REFUGEE-RELATED ISSUES
a) If the applicant has not been granted refugee status in the country of current
residence, please explain:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
b). Travel documents and/or identity documents (type, number, place and date of
issuance, issued by and valid until):
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
11
c). Candidate as applied for resettlement: __________ (Yes/No)
33. FINANCIAL ISSUES:
a) Amount requested from the Global Platform:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
b) Assessment:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_______________________________________________________________
36. Other remarks:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
37.
UNIVERSITY
APPLICANT SHORT-LISTED
YES/NO
COURSE ENROLMENT CONFIRMED
FINAL DECISION
REJECT
ACCEPT
AMOUNT GRANTED
NOTES:
Place and date:
Name :
Signature :
12