126--Applcation_form.docVIP

EURASIA 2 Application form - 2010/2014 – Asian applicants This application form should be completed in BLOCK letters in order to be easily copied and/or faxed. Please hand in your application form with ALL the required documents to your local coordinators. Only fully completed and signed applications can be accepted! 1. APPLICANT’S PERSONAL DATA Family name/Surname __________________________________ (same names as in the passport) First name(s) __________________________________ Current address __________________________________ (Where you can be contacted) __________________________________ __________________________________ __________________________________ Permanent address (if different) __________________________________ __________________________________ __________________________________ Phone (with country prefix) __________________________________ Mobile number __________________________________ Fax __________________________________ E-Mail __________________________________ Date of birth (DD.MM.YY) __________________________________ Place of birth, country __________________________________ Sex __________________________________ Nationality __________________________________ Native Language __________________________________ Family status __________________________________ Number of Personal ID Card + expiry date: _______________________________ or International Passport + expiry date: ______________________________ Please mark: ? Applicant from Target Group 1* ? Applicant from Target Group 2* ? Applicant from Target Group 3* *Please check: http://www.eurasia2.cz/page/application-process/ Application for (please choose only one option): ? Undergraduates ? 5 months or ? 10 months ? Masters ? 10 months or ? 22 months ? Doctorates ? 10 months or ? 34 months ? Post Doctorates ? 6 months ? Academic Staff ? 1 month 2. HOME INSTITUTION Full name of the Home Institution (university,