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C ENTRAL E UROPEAN U NIVERSITY

Date of Submission: Head of Department:

mm/dd/yyyy Signature

D D OC O CT TO OR RA AL L R R ES E SE EA AR RC CH H S S UP U P PO P OR RT T G G RA R AN NT T P P RO R OG GR RA AM M

A A PP P P LI L I CA C AT TI IO ON N F F OR O RM M F F OR O R 20 2 01 16 6- -2 20 01 17 7

P

I

Last name First name Middle initial

Male Female

Date of birth (dd/mm/yyyy) Citizenship Sex

Department/Program:

E-mail address:

When did you enroll in the doctoral program?

What year will you be in during the DRSG?

What is the expected date of completion?

Have you studied at CEU before your PhD? Yes No What program?

If CEU Fellowship recipient, how many months have you received funding to date?

Permanent address

Number & Street

City/State Zip/Post code Country

Telephone Fax Email

What period of time do you anticipate being abroad?

Months: one two three Other

Please give start and end dates: from to

mm/dd/yyyy mm/dd/yyyy

A

I

Name of Supervisor at host university or research institution

Name Department

Telephone Fax Email

Name and address of university or research institution you are intending to visit

Institution/Number &Street

City/State Zip/Post code Country

DECLARATION: I undertake to comply with the University’s regulations and policy on the Doctoral Research Support Grant Program

Signature

Check list (please tick in the box):

Statement of Purpose (max. 3 pages), including: Invitation letter from External Supervisor - Benefits of the visit for your research Letter of Acceptance from Host University

- Research Plan Information on living costs (on a monthly basis)

Confidential letter & form from CEU Supervisor Information on travel costs CV CEU Transcript (unofficial)

C ENTRAL E UROPEAN U NIVERSITY

B B UD U DG GE ET T R R EQ E QU UE ES ST T

Have you applied to other sources of funding? Yes No

If Yes, please attach a list of the sources and the deadlines by which you expect to receive an answer.

Please include the exchange rate:

F INANCIAL I NFORMATION :

Provide exact figures (in EUR) for the following:

Monthly Living Cost (housing & meals)

№ of months Sub total: € Monthly Health Insurance Cost

(please inquire as to the actual cost - it may be included)

№ of months Sub total: € Other Expenses (please give details below):

1. Visa Fees

2. Round trip airfare/train

3. Public transportation (monthly pass)

4.

5.

6.

Sub total: €

Tuition or Visiting Scholar Costs (if any)

Sub total: €

TOTAL COSTS(A)

TOTAL OF OWN RESOURCES SECURED (B)

TOTAL AMOUNT REQUESTED (A - B) FROM CEU