MAS-ICM Master of Advanced Studies (MAS) in Integrated Crop Management APPLICATION REQUEST FORM Submit by e-mail to: [email protected] I wish to apply for the DAS-ICM I wish to apply for the MAS-ICM Name : First name : Profession : Date of birth : Sex : Nationality : M F Country of residence : Private address : E-mail (private) : Phone (private) : Professional address : E-mail (prof.) : Phone (prof.) : Your education background (rank after highest degree obtained or in progress) : Name of Institution Degree Started Completed Specialisation If you studied in Switzerland please indicate your immatriculation number : Relevant professional experience (reverse chronological order) : Name and address of organisation/company Title Started DD/MM/YY Ended DD/MM/YY Key word responsibilities Please continue on the second page Language skills : Please use the following grades : 1= Basic, 2= Good, 3= Very good, 4= Fluent, 5= Native Language Reading Writing Speaking Proof of English proficiency (e.g. TOEFL) : In case of approval of this application request, I will be able to register for the MAS-ICM (or DAS-ICM). The course fee of CHF 15'000.- (respectively, CHF 14'000.- for the DAS-ICM) will have to be paid by me upon receipt of the registration invoice. I wish to apply for a scholarship* : Yes No * Only applicants holding a passport from a Plantwise country are eligible for a scholarship, for more information see the 'fees and funding' section on http://www2.unine.ch/mas-icm. Place and date : Signature :
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