In Ukraine and Moldova

SUMMER SCHOOL APPLICATION FORM

Democracy and Market Economy as Mechanisms of Conflict Prevention

in Ukraine and Moldova

15-19 June 2015

Grand Marine Hotel, Odessa, Ukraine

1. PERSONAL DETAILS & CONTACT INFORMATION

Last Name:

First Name(s):

Gender: ☐ Female ☐ Male Date of Birth:

Nationality:		Passport No.:
	Expiry Date:	Please choose date

Address:

Postcode and City:

Country:

Home Phone No.

Mobile No.: with Country Code

E-mail address:

Facebook (optional):

2. EMERGENCY CONTACT INFORMATION

Last Name:

First Name(s):

Relationship:

Phone No. With Country Code

E-mail address:

3. OTHER INFORMATION

Any allergies?
Any specific food requirements?

4. ENGLISH LANGUAGE PROFICIENCY

Please specify your command of English:

☐ A0 -Very Basic ☐ B1 - Intermediate

☐ A1 - Elementary ☐ B2 - Upper Intermediate

☐ A2 - Breakthrough ☐ C1/C2 – Proficient user

Please, specify how long you have been studying English and where:

If applicable, please specify the score obtained, the certificate (e.g. TOEFL, IELTS) and the date:

5. YOUR EDUCATIONAL BACKGROUND

· Home university, including the name of the faculty and the name of department and:

· Language(s) of instruction at your university:

Course of Study: ☐ Master ☐ Doctoral (PhD)

· Title of degree / specialisation:

· Last diploma obtained:

· Please, indicate your current Grade Point Average (GPA) / For PhD Students - your Masters’ GPA:

· Doctoral / Master thesis topic:

6. MOTIVATION STATEMENTS

Please use this space to write a brief explanation of your motivation to participate in the Summer School and a short biographical sketch about yourself (max. 800 words):

If you already have some publications, conference papers, essays, course works etc. related to the topic of the summer school (democracy and market economy as mechanisms of conflict prevention), please provide details on the topic, methods, etc. (max. 200 words):

7. DECLARATION

Please read the following declaration and sign it in the appropriate place below.

· I confirm that the information given in this form is correct and accurate.

· In case that I would be accepted for the coming summer school I will confirm my participation by e-mail within 5 days after the receipt of the invitation.

Signature (type your name in):		Date:

The selection of applications will be based on their originality, their scientific quality and their explicit reference the Summer School’s topic: “Democracy and Market Economy as Mechanisms of Conflict Prevention in Ukraine and Moldova”.

When sending the application form, please call it: SummerSchool2015_your_name

Please, title your e-mail: Summer School Odesa Application

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Дата добавления: 2015-07-26