1. Name
2. University degrees / diplomas
Degree
3. Prizes (university level and above)
Prize
Institution
Institution
Year
Year
4. Employment since clinical qualification (in reverse chronological order)
Post Institution Dates
5. Chosen specialty for higher specialist training; title and dates of specialist training posts held
LSHTM: WT PhD programme for clinicians: application form Sep 11 page 1 of 3

6. Intended career pathway
7. Relevant experience in low- or middle-income country settings (max 300 words)
8. Research training and experience (include any courses or specific training)
LSHTM: WT PhD programme for clinicians: application form Sep 11 page 2 of 3

9. Publications (only items published or in press: do not include conference presentations)
10. Ideas for a PhD research project (maximum 250 words). If you have discussed your plans with a potential supervisor, please tell us who the supervisor(s) is / are.
11. Please indicate how you heard about this programme.
BMJ BMJ Online
LSHTM job vacancies website
LSHTM – Wellcome
Clinical PhD website
12. Please provide a letter of support from an academic referee.
jobs.ac.uk
Other
LSHTM: WT PhD programme for clinicians: application form Sep 11 page 3 of 3