APPLICATION FORM - Centre for International Governance ...



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Exchange Program Application Form

|PERSONAL INFORMATION |

|All legal given or first names in full: | |

|Legal last name in full: | |

|Preferred Name: | |

|Gender: | |

|Date of birth: | |

|Country of citizenship: | |

|ADDRESS |

|Street, Unit or Apartment No.: | |

|City: | |

|Province or State: | |

|Country: | |

|Postal Code: | |

|Telephone: | |

|E-mail: | |

|PROGRAM OF CHOICE |

|Please indicate which option you are applying for |

|Option 1 |Student Exchange |

|Option 2 |PhD Dissertation Preparation |

|CURRENT AFFILIATION |

|Program currently enrolled in: | |

|Courses taken in current program: | |

|Research area: | |

|Expected completion date: | |

|ACADEMIC BACKGROUND |

|Enter details of all academic post-secondary institutions attended |

|Institution: | |

|From Date: | |

|To Date: | |

|Location of Institution: | |

|Address: | |

|Highest year/level achieved: | |

|Program studied: | |

|Degree/Diploma: | |

|Degree/Diploma status: | |

|Degree/Diploma date: | |

|Institution: | |

|From Date: | |

|To Date: | |

|Location of Institution: | |

|Address: | |

|Highest year/level achieved: | |

|Program studied: | |

|Degree/Diploma: | |

|Degree/Diploma status: | |

|Degree/Diploma date: | |

Relevant past research and/or work experience: List past research and work experience relevant to your proposal in reverse chronological order. Start each new item with the corresponding year.

|Year |Title/Position |Research/Project/Program Name |Details |

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I declare that the information in this application is correct and complete. I acknowledge that if evidence of misrepresentation or fraudulent or falsified documentation is found, CIGI and the host university reserves the right to revoke any offer or admission or support or to require the applicant to withdraw from the exchange program.

I understand and accept that CIGI and the host university may disclose evidence of any misrepresentation or fraudulent or falsified documentation to the involved Canadian institutions and Makerere Univiersity.

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Applicant signature

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Date

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