Please complete in typescript or in block letters using black ink.

Personal Information:

Surname/Last Name/Family Name: ________________________________________
First Name/Other Names: ________________________________________________
               Male ٱ  Female ٱ                  Mrs. ٱ  Ms. ٱ  Mr. ٱ Dr. ٱ

Correspondence Address (including Post Code):
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________		
Telephone Number: _________________________ Fax Number: _________________________________
Valid until: _______________________

Permanent Address (including Post Code):
_____________________________________________________________________
_____________________________________________________________________
Telephone Number: _________________________ Fax Number: _________________________________
E-mail: ___________________________________  E-mail: _____________________________________

Date of Birth: ______________________________ Country of Birth: ______________________________
Nationality:  _______________________________ Citizenship:  __________________________________
Country of Permanent Residence: ___________________________________________________________
Passport Number: __________________________ Valid Until: ___________________________________

Academic Qualifications Held or Pending:

Scientific Degrees (already Held or Pending):	
University/Institute or College	Dates of Attendance	Degree Obtained	Major Fields of Study	

				
Study and Research Opportunities Abroad (in Chronological Order)	

				

Proposed Research Project: 
_______________________________________________________________________________________

Name of Academic contact at the University, if any: 
_______________________________________________________________________________________

Have you been awarded any OSI Scholarships in the past? If yes, please, indicate the year and type of the Scholarship you received: 
________________________________________________________________________________________
________________________________________________________________________________________