Application for Support by students from Bangladesh already registered or accepted for a Ph.D.
or equivalent course in a British University or recognised institution of higher education in the
UK.
1. Name …………………………………………………………………………
2. M/F ………………….
3. Date of Birth………………………………………………………………….
4. Address in Bangladesh
………………………………………………………………………………………
………………………………………………………………………………………
5. Address in the UK (if applicable)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
6. Tel no…………………………………………………………………………
7. Email address ………………………………………………………………….
8. Details of educational qualifications
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
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9. UK Education Institution at which the applicant is registered for a post-graduate level course of
study (please send a copy of the registration document)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
10. Course registered for
………………………………………………………………………………………
11. Topic of research (This is a key selection criterion. Please include as much detail as necessary or
submit a summary on a separate sheet.)
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
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12. Current status of project / Expected date of completion
………………………………………………………………………………………
13. Name and contact address/ email of academic supervisor or contact within the UK educational
institution. A letter of support for your application from your academic supervisor is required
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
14. Purpose for which financial support is required
………………………………………………………………………………………
………………………………………………………………………………………
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15. Estimated sum required (Maximum £1,000) £ .................
16. Details of scholarships received or applied for, and of other sources of financial support.
[Applicants will need to satisfy the Trustees that they will have access to sufficient funds from other
sources to enable them to complete their course.]
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
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17. Proposed career on return to Bangladesh
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
………………………………………………………………………………………
Signed………………………………………………………….
Date ……………………………
Please send this completed form (preferably by e-mail) with additional material if desired to:
Tim Butchard, Secretary, The Charles Wallace Bangladesh Trust
4, Dorville Crescent, London W6 0HJ, The United Kingdom
E-mail: timbutchard@wallace-trusts.org.uk
March 2009
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