1”x 1” Recent Photo OVPAA-BPhD Form 8.0 UP Balik PhD Recruitment Program Application Form 1. Name (Last, First, Middle) 2. Gender: Male Female 3. Civil status: Single Married Divorced 4. Birth Date: Place: Citizenship: 5. If married: 5.1 Name of spouse: _________________________________________________ 5.2 Names and birth dates of minor dependents (if any): Names 5.2.1 _________________________________ 5.2.2 _________________________________ Birth date _________________ _________________ 6. Contact Nos.: Residence: Mobile: 7. E-mail address/es: 8. Type of current visa: 47 (a)(2) Others (please specify) _________________ 9. Planned Engagement (Please briefly describe.) 10. Identify contact person/s and institutions you wish to engage in the University of the Philippines System 10.1 Name: _____________________________________________ UP Unit: _____________________________________________ Address: _____________________________________________ E-mail Address: ________________________________________ 10.2 Name: _____________________________________________ UP Unit: _____________________________________________ Address: _____________________________________________ Email Address: ________________________________________ 20. Certification I certify that the foregoing answers are true and correct to the best of my knowledge and belief. _____________________________ Date of Application OVPAA-BPhDForm8.0.v4 053013/jcb ______________________________ Signature over Printed Name 1 OVPAA-BPhD Form 8.0 UP Balik PhD Recruitment Program Application Form 1. Name (Last, First, Middle) 21. Endorsements __________________________ Director/Dept. Chair ____________________ Dean ________________________________ Vice Chancellor for Academic Affairs ____________________ Chancellor Note: Accomplish this form and submit to the Chancellor of the CU/CUs concerned together with the following: a) Detailed/Updated Curriculum Vitae to include the following: - Educational Background - Field of Specialization - Areas of Research Interest - Professional/Employment/Work History including significant scientific, technological and/or entrepreneurial activities undertaken - Significant achievements (up to 3) related to your expertise or profession - Publications in international peer-reviewed journals, books, etc. (Indicate 3 most important publications.) - Relevant training - Fellowships/Grants - Relevant supporting documents (i.e., Transcript of Records for the PhD degree) b) Letter of Intent/Application Letter detailing plans for engagement (teaching, research, and extension) with the University (CU/CUs) and how, based on his/her reading of the Strategic Plans of the University (System and CU/CUs), his/her engagement is aligned. c) A Capsule Concept Proposal (OVPAA BPhD 8.1-8.4) including proposed research paper/s to pursue for possible publication, aligned with the thrust of the UP unit. OVPAA-BPhDForm8.0.v4 053013/jcb 2