/Lindemann-Application-Form

APPLICATION FORM FOR LINDEMANN TRUST FELLOWSHIP Candidates are responsible for ensuring that two confidential academic references are sent separately to the ESU before the application deadline. An electronic version of this form is available at www.esu.org Completed forms should be returned to: The Education Department English-Speaking Union, 37 Charles Street, London W1J 5ED education@esu.org Application deadline: 15 February 2012, please submit your application via email to the above email address Interviews: 17 April 2012 held at Dartmouth House, London 1. Contact details Name: Please circle one of the following: Telephone No:

D.O.B: Mr

Mrs

Miss

Other (please state) Mobile No:

Email:

Nationality:

Correspondence Address:

Permanent Home Address:

2. Research Subject of proposed research in the United States:

3. Education Schools attended:

Dates

A-Levels

Universities/Colleges attended:

Dates

Any title, degree or diploma for which you are a candidate:

Degrees/Diplomas

Expected date of award:

4. Scholarships & Awards Scholarships or fellowships held (please include present emolument and when it is due to terminate):

Any books, articles and theses published (please indicate any with a particular relevance to your proposed area of study in the United States and specify for which publications you are senior or joint senior author):

Any articles in print but not yet published:

Research activities (dissertation, special investigations, etc), with dates:

5. Occupation or Practical Experience Position: Name and address of employer:

Type of work:

Dates:

Profession for which you are preparing:

Institution in the United States with which you are in correspondence concerning your proposed research:

Any other sources of financial support, including personal funds (give name and address of each source, and attach any relevant documents):

Any other awards or fellowships for which you have applied (please state result of application):

Are there any members of your family whom you intend to take with you to the United States (please give name, relationship to you and age if under 16)?

If accompanied by your spouse, will he/she be seeking employment?

6. Referees Please give the names and addresses of your two academic referees:

STATEMENT OF PROPOSED RESEARCH Give a concise outline of your proposed research in the United States and its value to your future work here. This statement should be limited to five hundred words if possible: