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דרשמ

ץוחה

םילשורי

MINISTRY OF FOREIGN

AFFAIRS

JERUSALEM

ISRAEL GOVERNMENT SCHOLARSHIPS (Academic year: 20__

– 20__)

APPLICATION FORM

To be filled

out, in English, in triplicate

Country of origin:  ____________________

Scholarship required:

                 1. Short term Scholarship: Language Summer Course (Ulpan)

                 2. Long term Scholarship (One Academic Year = 8 months only):
                     Post Doctorate/ Research /Ph.D / M.A. / Overseas program

1.

Surname:

__________________

First name:

_________________

Place of birth: _______________

Citizenship:____________________

Date of birth: _______________

Gender:

Male / Female

Permanent address: _________________________________________

_________________________________________________________

Passport no.: ____________________

Telephone: _____________________ Cellular Phone: _________________

10.

Fax: ________________________

11.

E-mail: _________________________

12.

Marital status: _________________

13.

At which institution do you wish to pursue your studies or undertake research work?

A. _______________________________

B. ________________________________

C. _________________________________

Attach recent

photograph

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14.

Do you have a supervisor already? (for post doctorate and research students only)

YES Name of supervisor ___________________________________

(If yes, please enclose any letter you have from your supervisor.)

15.

Have you been in contact, or have you registered to any university or professor in Israel?

(Please indicate.)

_______________________________________________________________

16.

Have you been accepted by any university or professor in Israel? (Indicate and

enclose a letter of acceptance).

______________________________________________________________

17.

Current and Previous University Education:

List in chronological order, starting with your current enrollment, all colleges and universities you have

attended.

Name and Place of Institution

Major

No. of Years

Date of Graduation

Degree

18.

In which language will you conduct your research/studies in Israel? ______________

19.

Language Skills: (x

– none ; xx – poor ; xxx – fair ; xxxx – good ; xxxxx – fluent)

Languages

Reading

Speaking

Writing

Hebrew

English

Other (specify)

20.

Type of proof for language skills: _________________________________________

21.

Present occupation: ___________________________________________________

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22.

Detailed program for your studies in Israel. (If this space is insufficient, please use

a separate sheet and attach it to this form as an appendix).

___________________________________________________________________

23.

Other details that you consider important for the evaluation of your application.

___________________________________________________________________

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MEDICAL HEALTH CERTIFICATE

1. Name: _______________________________________

2. Place of birth: _________________________________

3. Date of birth: _________________________________

4. Address: _____________________________________

____________________________________________

5. Person to be notified in case of emergency:

Name: _______________________________________

Full address: __________________________________

_____________________________________________

Telephone no.: __________________

Cell phone no.: __________________

Fax no.: ________________________

E-Mail: _______________________________________

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The following details are to be supplied by a registered medical practitioner:

1. Past medical history: ____________________________________________________

____________________________________________________________________

2. Present state of health: __________________________________________________

____________________________________________________________________

3. Results of general examination:

Blood pressure: _________

Weight: __________ Height: __________

4. Is the applicant suffering from:

An infectious disease? _________________________________________

A skin disease? ______________________________________________

A psychological disorder? ______________________________________

Cardiac condition? ___________________________________________

Any other diseases? __________________________________________

5. Remarks: __________________________________________________

_________________________________________________________

6. Is the applicant in good health and able to physically and mentally engage

in intensive studies in a foreign country? ________________________________

_________________________________________________________________

Name of examining physician

Signature of examining physician

___________________________

__________________

Date of examination: __________________

To be signed by the applicant:

I, the undersigned, declare that all of the above information in this application forms is complete and

accurate to the best of my knowledge. I am aware that giving incorrect answers to any of the above

questions may lead to the cancellation of my application.

Date: ____________

Signature: ____________________