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
English Language (IELTS) Scores
Highest Educational
& Other Qualifications (Year & Institutional
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)
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
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