2016-17 JANSSEN PHARMACEUTICA SCHOLARSHIP APPLICATION FORM Please tick the following before completing the application form: I have applied for admission from King’s College London for 2016-17 MSc Global Mental Health If I am short-listed for this funding, I will provide proof of my English language proficiency by submitting IELTS test results at that time. Please note that your application will not be processed further if you have not fulfilled the above. Family Name or Surname First Name/s Address for the past 3 years Contact Telephone No. Contact Email Address Nationality English Language (IELTS) Scores Highest Educational University/College) Degree (Year & Other Qualifications (Year & Institutional Affiliation) Professional Qualifications (if any) Name & Email Address of 1st Referee Name & Email Address of 2nd Referee List up to three (3) relevant work/volunteer experiences (include addresses, dates, descriptions of responsibilities, and name of contact person) List up to three (3) most relevant achievements related to Global Mental Health Describe how, upon completion of the MSc in Global Mental Health, you intend to use your newly acquired training and skills to improve the lives of people with mental illness in low- or middle-income countries (in approx 500 words) DECLARATION 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 I agree to write a thank-you letter to the donor I confirm that the information given in this form is true and accurate. Signature __________________________________ Date ___________________ Applications will only be accepted where this form is hand-signed or an electronic signature is attached. If you have any questions please contact Alex Cohen (one of the MSc Global Mental Health Course Directors): Alex.Cohen@lshtm.ac.uk Please return by email to: scholarships@lshtm.ac.uk by the scholarship deadline. Registry, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT