2016-17 APPLICATION FOR TEG FELLOWSHIP AT LSHTM
1. PERSONAL DETAILS
Surname:
___________________________________
Title:
Dr/Mr/Mrs etc
First names:
___________________________________
Gender:
Male
Nationality:
___________________________________
Date of birth: day / month / year
Female
Permanent Address:
Correspondence Address:
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Postcode
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Postcode
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Country
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Country
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Telephone
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Telephone
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Mobile
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Email address
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2.
(we will use email as the main
method of contacting you)
HIGHER EDUCATION (degrees held or currently being taken)
University/College
Qualification
(BSc/MSc etc)
Subject
Course Dates
From
To
Final
Result
Language of
instruction
______________________
____
__________________
m/y
m/y
______
________________
______________________
____
__________________
m/y
m/y
______
________________
______________________
____
__________________
m/y
m/y
______
________________
______________________
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__________________
m/y
m/y
______
________________
______________________
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m/y
m/y
______
________________
IMPORTANT: A scanned/electronic copy of each transcript must be submitted with your application form
Please give details of your highest
mathematics qualification or any
mathematical/statistical experience
_________________________________________________________
_________________________________________________________
_________________________________________________________
3.
LANGUAGES
First Language:
___________________________________________________________________
Other Languages:
___________________________________________________________________
4.
EMPLOYMENT
From
To
Type of Contract
(fixed, temporary
or permanent)
m/y
m/y
_____________
_________________________
_________________________
m/y
m/y
_____________
_________________________
_________________________
m/y
m/y
_____________
_________________________
_________________________
m/y
m/y
_____________
_________________________
_________________________
m/y
m/y
_____________
_________________________
_________________________
Dates of Employment
Responsibilities
Name and Address of
Employer (including country)
NB: Please also send a full electronic version of your CV with this application
5.
REFERENCES
You must supply TWO references. If you have studied in the last 5 years please include a reference from an
academic familiar with your work and a second reference from your employer.
FIRST REFEREE:
SECOND REFEREE:
Name:
_____________________________
Name:
_____________________________
Position:
_____________________________
Position:
_____________________________
Address:
_____________________________
Address:
_____________________________
____________________________________________
___________________________________________
____________________________________________
___________________________________________
Telephone:
_____________________________
Telephone:
_____________________________
Email:
_____________________________
Email:
_____________________________
NB: Reference forms can be downloaded from the LSHTM website. Please complete section 1 (applicant details)
of the form and send an electronic copy to each referee. You should ask each of your referees to return the
reference directly to teg@LSHTM.ac.uk by 17th April 2016. Applications received without two references will
not be considered.
6.
PERSONAL STATEMENT
Your personal statement should include reasons for why you wish to apply for the TEG Fellowship, why you think that
you would be a suitable candidate and how your past academic/employment experience has equipped you for the
Medical Statistics MSc/TEG Fellowship.
7.
RETURNING THE APPLICATION
Please return this application form (along with your CV and academic transcripts) by email to
teg@LSHTM.ac.uk. Please write “TEG Fellowship Application” and your name in the subject line of the email.
The completed application form must reach LSHTM by 17th April 2016. Applications received after this date will
not be considered. We will send a confirmatory email upon receipt of the completed application form, so please
ensure that we have a correct and up-to-date email. We advise that you check your email regularly.
A panel of staff from LSHTM will decide on a short-list of candidates based on the completed application form
and references. The short-listed candidates will be interviewed by telephone in May. The successful candidate
will be informed shortly after the interviews have been completed.
If you are currently applying for other sources of funding for the MSc in Medical Statistics at LSHTM then we
advise that you should also complete the MSc application on which you should state the source of your funding.
Those applying only for the TEG Fellowship should not apply separately for the MSc.
Please check that you have:
completed all sections of the application form
enclosed your academic transcript(s)
enclosed your Curriculum Vitae/Resumé
sent the TEG fellowship referee form to two referees and asked
them to forward their reference to teg@LSHTM.ac.uk
read and signed the declaration below
DECLARATION (please read and sign below)
I certify that the statements made by me on this form are correct and complete.
Name:
__________________________________
Date:
___________________