VITALITY AND AGEING FUND
Medical Master Vitality and Ageing
Application Form
Vitality and Ageing Fund
c/o Leyden Academy on Vitality and Ageing
Rijnsburgerweg 10, 2333 AA Leiden
The Netherlands
E-mail: info@leydenacademy.nl
Website: www.leydenacademy.nl
Please fill in electronically if possible, except for original signature in the
declaration.
Personal information
Family name (as mentioned in passport)
First name(s) (as mentioned in passport)
Do you have dual nationality: yes / no. If yes, please indicate which:
Date (dd/mm/yyyy):
 Female
 Male
Place of birth:
Titels:
Present address (mailing address):
E-mail:
Cell phone:
Telephone:
Fax:
Educational background
Name and address of present / past University or College
Year of Entry
(Current) Major
(Expected) Date of graduation
Degree(s) and /or Certificates Obtained:
Current or past Study / Current or past Research at University
Study
Postgraduate (Master’s) Programme name:
Duration:
From:
Until:
(dd/mm/yyyy)
Research Brief description / Title of research project (max. 25 words) (only for research)
Funding
Have you applied for financial assistance elsewhere? Please give details, including copies of the
outcome of application.
Scholarship
The scholarship is offered on the condition that you will be able to fund any shortfall between the
scholarship and the tuition fee yourself. The tuition fee amounts to € 18,100,-- for 2011-2012. In
general, the scholarship can be any amount up to € 13,600,--. Please indicate for what amount you
would like to apply and give details why you come to this amount.
Please Note:
* Indicate whether scholarships have been granted or applied for and also submit copies of the result.
Motivation letter covering the following items
-
- Aim,
- Relationship between the Master Vitality and Ageing and future career,
- Explanation of why this scholarship is needed.
If necessary use extra page.
Survey
Please fill out this short survey. It will help us to update and maintain our information.
Please indicate how you initially learned about the Fund:
 Via World Wide Web
 Contact with Leiden University (personal, phone, visit) OR Leyden Academy
 Via our brochures and/or flyers
 An education exhibition. Please specify which one:

Other. Please specify:
Checklist
I have included the following documents with my application (all documents should be in English.
Non-English documents should be translated into English and be certified by an official translator)

Admission letter of the Leiden University to the Master programme Vitality and Ageing

2 original letters of recommendation (of which one should be from an academic staff member)

Transcript of academic records

Up-to-date curriculum vitae

Letter of motivation which mentions why you apply for the scholarship

Photocopy of your valid passport(s)

Copy of results of other scholarships / grants
Please provide an explanation if you did not provide the required information with this application.
Use a separate sheet if necessary.
Declaration
I hereby declare that the information herewith enclosed has been provided in good faith.
Signature:
Date:
Place: