Appendix 1 Application form

APPLICATION FORM

Name, first name, title(s)   Male/female
Date of birth   Date of PhD  
Nationality  
Field of research o   Alfa/Gamma, namely
o   Beta, namely
o   Medical, namely
Institution* o   Leiden University
o   Leiden University Medical Center
o   Erasmus University Rotterdam
o   Erasmus Medical Center
o   Delft University of Technology
Hosting group*  
Places of residence three years prior deadline
Address   Period of residence
Zipcode    
Town    
Country    
If applicable second place of residence   Period of residence
Address    
Zipcode    
Town    
Country    
If applicable third place of residence   Period of residence
Address    
Zipcode    
Town    
Country    
     
Summary of proposal (max 500 words)  

 

 

 

 

 

 

 
 

 

*You have to enclose a support statement from the chair of the group that will host you. More information see application guide.