7/23/2019 Janssen Pharmaceutica Scholarships Application Form

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2016-17 JANSSEN PHARMACEUTICASCHOLARSHIP APPLICATION FORM

Please tick the following before completing theapplication form:

I have applied for admission from KingsCollege London for 2016-17 MSc Gloal Men!al "eal!h

If I am shor!-lis!ed for !his f#nding$ I %ill provide proof of m& 'nglish lang#age proficienc& &s#mi!!ing I'L(S !es! res#l!s a! !ha! !ime)

Please note that your application will not be processed further if you have not fulfilled theabove.

Family Name or Sr!ame Fir"# Name$"

A%%re"" &or #'e (a"# ) year"

Co!#a*# Tele('o!e No+ Co!#a*# Email A%%re""

Na#io!ali#y E!,li"' La!,a,e IELTS. S*ore"

Hi,'e"# E%*a#io!al /e,ree ear U!ier"i#y$Colle,e.

O#'er 3ali&i*a#io!" ear I!"#i##io!alA&&ilia#io!.

Pro&e""io!al 3ali&i*a#io!" i& a!y.

Name Email A%%re"" o& 1"#Re&eree Name Email A%%re"" o& 2!%Re&eree

Li"# ( #o #'ree ). relea!# 4or5$ol!#eer e(erie!*e" i!*l%e a%%re""e" %a#e"%e"*ri(#io!" o& re"(o!"i8ili#ie" a!% !ame o& *o!#a*# (er"o!.

Li"# ( #o #'ree ). mo"# relea!# a*'ieeme!#" rela#e% #o 9lo8al Me!#al Heal#'

7/23/2019 Janssen Pharmaceutica Scholarships Application Form

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/e"*ri8e 'o4 (o! *om(le#io! o& #'e MS* i! 9lo8al Me!#al Heal#' yo i!#e!% #o "eyor !e4ly a*:ire% #rai!i!, a!% "5ill" #o im(roe #'e lie" o& (eo(le 4i#' me!#al ill!e""i! lo4- or mi%%le-i!*ome *o!#rie" i! a((ro ;00 4or%".

*'CL+,+(I.If I am s#ccessf#l in gaining a scholarship

I give consen! for !he School and i!s scholarship par!ners !o anno#nce m& name and !he

a%ard$ and !o #se pho!ographic images of me$ in !heir p#lica!ions and %esi!es) I alsoconsen! !o %ri!e a 2/0 %ord s!#den! profile for #se in p#lica!ions

I consen! !o m& applica!ion forms$ !ranscrip!s and references eing released !o !he

scholarship s#panel

I agree !o %ri!e a !han-&o# le!!er !o !he donor

I confirm !ha! !he informa!ion given in !his form is !r#e and acc#ra!e)

Signa!#re *a!e

Applications will only be accepted where this form is hand-signed or an electronic signature isattached.

If &o# have an& #es!ions please con!ac! +le3 Cohen 4one of !he MSc Gloal Men!al "eal!hCo#rse *irec!ors5+le3)Cohenlsh!m)ac)#

8lease re!#rn & email !o scholarshipslsh!m)ac)# & !he scholarship deadline),egis!r&$ London School of "&giene 9 (ropical Medicine$ Keppel S!ree!$ London :C1' 7"(

mailto:Alex.Cohen@lshtm.ac.ukmailto:Alex.Cohen@lshtm.ac.ukmailto:scholarships@lshtm.ac.ukmailto:scholarships@lshtm.ac.ukmailto:Alex.Cohen@lshtm.ac.uk