Family name:

Personal names:

Male (  ) Female(  )  

Address for correspondence:

Phone:   Area Code:               No:

E-mail:

Picture (4*3)

Nationality:

Date of birth:

Year/month:

Names and address of education establishments

Indicate Degrees: BSc,  MSc (or their equivalents) and areas of specialization

From:

To:

Are you presently studying? Yes:         No:
IF YES: What are you studying?

In which Institution? Name:
                                   Address:

Title of Position:

Starting date:

Permanent:         Temporary:

In case of approval, amount of time devoted  to:
study: %; research: %; administration: %

Is your institution:
Government ( ) NGO (  ) University (  ) Private sector (  ) Other (  )

Specify if other:

Research area or other responsibility:

Year/month

Name and address of employers

Research area or other responsibility

From

To

Name and postal address of Institution:

Name of head of institution:

Phone:   Area Code: No:

Telefax: Area Code: No:

E-mail:

Name (and postal address) of Department or research station: 

Name of immediate supervisor:

Phone:   Area Code: No:

Telefax: Area Code: No:

E-mail:

3.1.1 Improving the well- being of the rural poor:

3.1.2 Sustainable use of renewable natural resources:

3.1.3 Mitigation of, or adaptation to, Climate Change:

Define the problem to be addressed:

What is the hypothesis you wish to test?

Describe briefly the research you will do to test the hypothesis



 

Are you presently carrying out any research related with this topic?

Any other comments you wish to make?

I understand and agree that during this course I will be required:
(i) to carry out practical tasks on farms
(ii) to live with farmers and villagers sharing their experiences
(iii) to do my research project on-farm as well as on-station
(iv) to communicate via e-mail during the 2 year period of the course

 Date:                                                                         Applicant's Signature

I agree that following the successful completion of the course I will continue to work for my institution for at least THREE further years

Date:                                                                         Applicant's signature

I certify that the information provided above is correct.

Date:

Signature of the applicant

This application is approved and the facilities of the institution including personnel, building, equipment and financial resources will be provided to the applicant in accordance with the specifications of the proposal.

Date: Stamp of the Institution:

Signature of Head of Institution