PhD Program in Cancer and Immunology

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1 Application Form 2010 APPLICATION DEADLINE: MAY 1ST, 2010 Please print clearly or type APPLICATION (Please, fill in with the name of the thesis director you have chosen from the list provided on our website: You should indicate 3 choices, if possible: ) PERSONAL INFORMATION 1. Mr Ms 2. Legal family name 3. Legal first name(s) 4. Country of citizenship If you are not a Swiss citizen, do you have a Swiss residence permit? Yes No If yes, type of permit A B C Date of birth (DD/MM/YYYY) 5. Place of birth (for Swiss citizens, place of citizenship) 6. Marital status Single Married Divorced children (Nbr): Address where we can permanently reach you (e.g. your parents' address) Family name First name Street Additional information (residence) Town Postal code Region Country Tel (with international code) Fax (with international code) address 1

2 Your current address, if not identical to your permanent address Street number Additional information (residence, ) PO Box Postal code Town Region Country Tel (with international code) Fax (with international code) address 2

3 Application Form 2010 Please print clearly or type PhD Program in Cancer and Immunology ACADEMIC AND WORK EXPERIENCES 7. List all universities, colleges or other academic institutions attended since high school. Do not abbreviate names of institutions. Include in your application certified transcripts listing courses and all your grades for all studies at these academic institutions. These transcripts must be translated into English if not originally in French, German, Italian or English. Start from the most recent diploma 8. Institution name and location Major field of study Dates attended from to Duration of study* Date** Degree** 9. * towards this degree, full time and with no failures or interruptions ** Conferred or expected 3

4 ACADEMIC AND WORK EXPERIENCES 10. List all universities, colleges or other academic institutions attended since high school. Do not abbreviate names of institutions. Include in your application certified transcripts listing courses and all your grades for all studies at these academic institutions. These transcripts must be translated into English if not originally in French, German, Italian or English. Institution name and location Major field of study Dates attended from to Duration of study* Date** Degree** 4

5 List occupations, other than as a student, in which you have engaged to any considerable extent, giving names and location of employers and dates of employment. Include military service and any teaching or voluntary work experience you have had. Occupation / responsibility Employer / location Time period 11. List publications (books, articles, short reports, ) or inventions you have patented Presentations Date Location Title 12. List academic honours, prizes and fellowships you have received 13. Fellowship/Prize Date 5

6 LANGUAGES 14. List all languages you know and your level in written and oral expression Written Oral poor fair fluent poor fair fluent poor fair fluent poor fair fluent Arabic (Native) poor fair fluent poor fair fluent poor fair fluent poor fair fluent poor fair fluent poor fair fluent 15. List language of instruction in Primary school Secondary school University Graduate school 16. Indicate here your TOEFL and GRE scores if available (not mandatory, but highly recommended for students who have not followed more than three years of study in French or English) TOEFL. GRE verbal quantitative analytical Alternative test(s) / certificate (s) of English or French proficiency.... 6

7 YOUR REFEREES 17. List of 3 referees (it is mandatory) 1. Name Address Tel & In the capacity of 2. Name Address Tel & In the capacity of 3. Name Address Tel & In the capacity of 7

8 STATEMENT OF OBJECTIVES Please list here your main subjects of scientific interest (present and future) and potential hosting laboratories. Include as far as you can your particular interests, be they experimental, theoretical or issue-oriented, and show how your background and our programme support these interests (1 page max.). 8

9 CERTIFICATION SHEET I certify that I have read all the instructions and that information in this application is true and complete. I understand that misrepresentation may be a cause for cancelling my admission or appointment. I understand that all credentials and documents I submit become the property of the Faculty of Biology and Medicine, UNIL, Lausanne. Place/date Signature. Please send by regular mail OR BY your complete application, without binding or staples, to : PhD Program in Cancer and Immunology Administration Office Department of Biochemistry (DB-UNIL) Chemin des Boveresses 155 CH-1066 Epalinges Switzerland Enclosures (please check that application is complete before mailing) The application form Copy of your high school diploma and grades Copies of your official transcripts of diplomas and grades from all academic institutions of higher education you have attended and their translations into English if not originally in French, German, Italian or English Copy of GRE or TOEFL (or other certificates of language proficiency) if applicable (not mandatory) Curriculum Vitae Three letters of recommendation signed by your referees (can also been sent by ). 9

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