Department of Social Science, Health & Medicine Visiting Application Form To apply to be a visitor at the Department of Social Science, Health & Medicine, King’s College London, please complete this form. You should have an agreement in principle from a member of the Department of Social Science, Health & Medicine staff to act as your sponsor/supervisor while at King’s. Once completed, please submit this form to your prospective sponsor/supervisor so that a supporting statement can be provided. Your application will then be considered by the Department Research Committee. Please note that having an agreement in principle from a member of staff to supervise you does not guarantee that you will be accepted by the Department Research Committee. Personal details Surname/Family name First name(s) Title (eg Mr, Ms, Dr) Date of birth Address Email address Telephone number(s) Nationality Country of birth Country of permanent residence In which country are you currently living? Funding Please tell us how you are planning to fund your fees and living expenses for the duration of your visiting research: 1 SSHM-VA version 2014-Oct-LB Sponsorship Proposed sponsor within SSHM Proposed dates of attendance at King’s Visiting Professor Visiting Senior Lecturer Visiting Lecturer Visiting Senior Research Fellow Visiting Research Fellow Visiting Postdoctoral Fellow Visiting Research Associate (please fill in “Details of previous study” section) Visitor status applying for Details of previous study – for Visiting Research Associates Institution of current study Present Position Date started MPhil/PhD Proposed supervisor at King’s Proposed dates of attendance at King’s Previous qualifications Please provide details of your previous university-level study Institution Dates attended Title of programme/field of study Qualification and result English language proficiency Please select one of the following statements: I have been taught and examined in English for my entire education to date I have been taught and examined in English for part of my education to date (Please state most recent period ) If you have taken a specific English language test, please state here: Candidate number: Score achieved: 2 SSHM-VA version 2014-Oct-LB Short outline of project to be undertaken at King’s Please write no more than 750 words. The outline should include an explanation of why your research would benefit from being located at the Department of Social Science, Health & Medicine, how you would expect to contribute to the Department, how often you would be here, and what resources you would need. Research Proposal Why SSHM and King’s College London? How would you contribute to the department? Timing and duration of visit (please also state how much time you intend to spend physically in the Dept) Resources required Research Groups Please indicate which Research Group you are applying to belong to during your visit Ageing & Society BIOS+ (further details) Please note that from October 1st 2015 BIOS+ replaces the previous groups “Biomedicine, Ethics & Social Justice” and “Biotechnology, Pharmaceuticals & Public Policy”. The BIOS+ research group conducts research on the nature and role of life sciences and biotechnologies in society. Drawing on a range of disciplines across the social sciences and humanities (primarily sociology and philosophy, but also history, science and technology studies, anthropology), BIOS+ explores issues of social justice, democracy, and social and individual identity, in the context of scientific and technological innovation. We investigate knowledge production and translation, regulation and public policy for biosciences and biotechnologies, sociotechnical systems and imaginaries. This work aims to inform, and when appropriate, transform science and health policy. Culture, Medicine & Power (further details) Give a brief explanation of why your research fits within this group: 3 SSHM-VA version 2014-Oct-LB Curriculum Vitae Please include here an up-to-date CV with this application form. Please limit your CV to two sides of A4. 4 SSHM-VA version 2014-Oct-LB Queries If you have any queries contact susan.chandler@kcl.ac.uk Declaration When you sign the declaration on the application form, you agree that King's College London can process your information and keep a copy of your form to collect statistics and detect and prevent fraud. The Data Protection Act allows you to ask for a copy of all the information we have about your application. I confirm that the statements made by me on this form are correct. I understand that if any of the above statements prove to be incorrect the College reserves the right to withdraw any offer made or cancel any subsequent registration with the College. I have read the guidance notes; I undertake to be bound by the terms set out in them and I give my consent to the processing of my data by King’s College London. King’s College London reserves the right, at any time, to request that you, your referees, or your employer, provide further information relating to any part of your application form, e.g. proof of identification, of status, of academic qualifications and/or employment history. Any offer of a place that you may receive is made on the understanding that, in accepting it, you agree to abide by the rules and regulations of King’s College London. Signed................................................................................. Date.................................................................. PROSPECTIVE SPONSOR SUPPORTING STATEMENT Signed................................................................................. Date.................................................................. 5 SSHM-VA version 2014-Oct-LB