FINANCIAL AID APPLICATION FORM (Deadline: February 23, 2015) Seminar Dates: March 23, 2015 – March 27, 2015 Please complete this form in full, by computer or by hand, and print clearly in black ink. If additional space is required, attach a separate sheet, indicating the section number that it refers to. PLEASE COMPLETE THE APPLICATION IN ENGLISH Return by post to: Attach a personal
photo to this
application MBH Guicciardini Palace Via S. Spirito, 14 -­‐ Lungarno Guicciardini, 7 50125 Florence Italy Or e-­‐mail to: [email protected] For assistance: [email protected]
+39 055 2645935 I PERSONAL INFORMATION Last name: First name: Current address: City: Telephone: Postal code: Country: Mobile: E-­‐mail address: 1 II EDUCATIONAL BACKGROUND Full Name of the Faculty/University Duration (from-­‐to) Degree Obtained III EXTRA CURRICULUM (brief description) Courses or workshops attended in reference to professional work or your interests IV LANGUAGES (Please note that the seminar will be held in English – students applying for financial aid who do not speak, read and write proficiently in English may not be accepted) Rate your language proficiency from 1 (poor) to 3 (acceptable) to 5 (very good) English: Spoken Understood Written Other Language: V PRESENT EMPLOYMENT Institution or organization: Address: Telephone: E-­‐mail: Position and responsibilities: 2 VI Past Employment Institution or organization: Duration (from – to): Position and responsibilities: Institution or organization: Duration (from – to): Position and responsibilities: Institution or organization: Duration (from – to): Position and responsibilities: VII PERSONAL STATEMENT (Max. 150 words) Explain why would like to participate in the seminar, what you hope to learn from it, and how it will benefit your personal or professional development. 3 VIII REFERENCES Please insert details of two persons who will act as your references Name: Title or Position: Institution or Organization: Contact: Name: Title or Position: Institution or Organization: Contact: IX AUTHORIZATION OF THE DIRECTOR OF THE INSTITUTION OR HEAD OF THE DEPARTMENT WHERE YOU ARE CURRENTLY EMPLOYED – IF APPLICABLE. (A confirmation that they support your participation and that they will approve your absence from work) Name: Title or Position: Institution or Organization: Signature of person endorsing application: Date: Stamp of Institution: X CANDIDATE STATEMENT I declare that the above information is true and correct. Signature of candidate: Date: Note: If you will need any kind of assistance from the organizers during your stay in Florence, please send an inquiry to: [email protected] stating ‘WAD Assistance’ in the subject field. 4