APPLICATION
(Please, fill in with the name of the thesis director you have chosen from the list provided on our website: http://www.unil.ch/cancer-immunology
. You should indicate 3 choices, if possible:
1) …………………………………………………………..……………
2) …………………………………………………………..……………
3) …………………………………………………………..……………
3)
P ERSONAL I NFORMATION
1.
2.
Legal family name
3.
Legal first name(s)
 Mr  Ms
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4.
Country of citizenship
If yes, type of permit
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If you are not a Swiss citizen, do you have a Swiss residence permit?  Yes  No
 A  B  C
Date of birth (DD/MM/YYYY) …………………………………………………………………
5.
Place of birth (for Swiss citizens, place of citizenship) …………………………………………………………………
6.
Marital status  Single  Married  Divorced children (Nbr): ……………..
Address where we can permanently reach you (e.g. your parents' address)
Family name
First name
Street
Additional information
(residence, …)
Town
Postal code
Region
Country
Tel (with international code)
Fax (with international code)
Email address
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PhD Program in Cancer and Immunology
Your current address, if not identical to your permanent address
Street number
Additional information
(residence, …)
PO Box
Postal code
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…………………………………………………………………………….. Town
Region
Country
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Tel (with international code) ……………………………………………………………………………..
Fax (with international code) ……………………………………………………………………………..
Email address ……………………………………………………………………………..
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A CADEMIC AND W ORK E XPERIENCES
7.
List all universities, colleges or other academic institutions attended since high school. Do not abbreviate names of institutions. Include in your application certified transcripts listing courses and all your grades for all studies at these academic institutions. These transcripts must be translated into English if not originally in French, German, Italian or English. Start from the most recent diploma
8.
9.
Institution name and location Major field of study Dates attended from to
Duration of study* Date** Degree**
* towards this degree, full time and with no failures or interruptions ** Conferred or expected
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PhD Program in Cancer and Immunology
A CADEMIC AND W ORK E XPERIENCES
10.
List all universities, colleges or other academic institutions attended since high school. Do not abbreviate names of institutions. Include in your application certified transcripts listing courses and all your grades for all studies at these academic institutions. These
transcripts must be translated into English if not originally in French, German, Italian or English.
Institution name and location Major field of study Dates attended from to
Duration of study* Date** Degree**
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PhD Program in Cancer and Immunology
List occupations, other than as a student, in which you have engaged to any considerable extent, giving names and location of employers and dates of employment. Include military service and any teaching or voluntary work experience you have had.
Occupation / responsibility Employer / location Time period
11.
List publications (books, articles, short reports, …) or inventions you have patented
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12.
List academic honours, prizes and fellowships you have received
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PhD Program in Cancer and Immunology
L ANGUAGES
13.
List all languages you know and your level in written and oral expression
Written
English  poor  fair  fluent  poor
Oral
 fair  fluent
French 


poor
poor
poor



fair
fair
fair



fluent
fluent
fluent



poor
poor
poor
 poor  fair  fluent  poor




fair
fair
fair
fair




fluent
fluent
fluent
fluent
14.
List language of instruction in
Primary school ……………………………………. Secondary school …………………………………….
University ……………………………………. Graduate school …………………………………….
15.
Indicate here your TOEFL and GRE scores and provide copies of records if available (not mandatory, but highly recommended for students who have not followed more than three years
of study in French or English)
TOEFL ……………………………….
GRE verbal …………… quantitative …………… analytical
Alternative test(s) / certificate (s) of English or French proficiency
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PhD Program in Cancer and Immunology
Y OUR R EFEREES
16.
List of 3 referees (it is mandatory)
1. Name …………………………………………………………………………………………………………………………
Address …………………………………………………………………………………………………………………………
Tel & Email:
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In the capacity of …………………………………………………………………………………………………………………………
2. Name …………………………………………………………………………………………………………………………
Address …………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
Tel & Email: …………………………………………………………………………………………………………………………
In the capacity of …………………………………………………………………………………………………………………………
3. Name
Address
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………………………………………………………………………………………………………………………… Tel & Email
In the capacity of …………………………………………………………………………………………………………………………
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PhD Program in Cancer and Immunology
S TATEMENT OF OBJECTIVES
Please list here your main subjects of scientific interest (present and future) and potential hosting laboratories. Include as far as you can your particular interests, be they experimental, theoretical or issue-oriented, and show how your background and our programme support these interests (1 page max.).
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PhD Program in Cancer and Immunology
C
ERTIFICATION
S
HEET
Place/date
………………………………………………….
Signature
Please send by regular mail,
staples, to :
your complete application, without binding or
Mrs Françoise Flejszman
PhD Program in Cancer and Immunology
Administration Office
Department of Biochemistry, fUNIL 
 chemin des Boveresses 155
CH-1066 Epalinges, Switzerland
Enclosures
(please check that application is complete before mailing)
 The application form


Copy of your high school diploma and grades
Copies of your official transcripts of diplomas and grades from all academic institutions of higher education you have attended and their translations into
English if not originally in French, German, Italian or English
 Copy of GRE or TOEFL (or other certificates of language proficiency) if applicable (not mandatory)
 Curriculum Vitae
 Three letters of recommendation signed by your referees
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