Anglo Czech Educational Fund
Registered Charity Number: 1110348

APPLICATION FORM

PERSONAL DETAILS		
Surname		
First Name		
Title		
Date of Birth		
Nationality		
		
Address		
		
Post Code		
Telephone		
Email		

PROGRAMME OF STUDY APPLIED FOR:
(Course Name/Project Title/Research Area of Interest)

	

FULL/PART TIME :

PLACE OF STUDY :  

EDUCATIONAL QUALIFICATIONS
Please give details of your main qualifications to be considered (degree, masters, vocational qualification etc.) List in reverse chronological order giving the most recent first.  Certificates/transcripts should be made available if requested.
Qualification Title	Grade or Class	Name of Institution	Awarding Body	Date of Award	

PROFESSIONAL AND OTHER QUALIFICATIONS
Please give details of your main qualifications to be considered. List in reverse chronological order giving the most recent first.  Certificates/transcripts should be made available if requested.
Qualification Title	Awarding Body	Date of Award	

	

EMPLOYMENT EXPERIENCE
Name and Address of Employer	Title and Duties of post	Dates	
		From	To	

ADDITIONAL INFORMATION
Please use this space to provide any additional information that you feel might be relevant.
Please indicate why you would like to study abroad and in what way it will benefit you as opposed to studying in the Czech Republic.	

	
REFEREES
Please give two details of referees below.
Name		Name		
Position		Position		
Organisation		Organisation		
Address		Address		

Post Code		Post Code		
Country		Country		
Telephone		Telephone		
Email		Email		

AVAILABILITY FOR INTERVIEW
Please indicate any periods where you may not be available

	

DECLARATION
I can confirm that, to the best of my knowledge, the information given in this form is correct and complete.  I understand that the decision to offer me a grant rests solely with the Trustees of the Anglo Czech Education Fund and is not subject to appeal.

Signature of Applicant:	_________________________
Date	:			_________________________