Surname :        
 First name/s :   
 E-mail address : 
 Postal address : 
                  
 Date of Birth  : (D/M/Y)  Age :  Sex (M/F) 
 Place of Birth :  Nationality : 
 Marital Status : 
 No. of Children and Age: 

B. EDUCATION

 Academic Qualifications :
 (University or equivalent)  Years attended  Major fields of study   Degree
                               From / To
         
         
         
         
         

C. SCIENTIFIC PUBLICATIONS

D. EMPLOYMENT

 Present position :  
 Institution :       
                            
 Dept./Faculty :     
 Address :           
                     
                     
                     Tel:  Fax:  Telex:  


 Current research and areas of interest : 
 


 Institutes of work since end of formal education :
 Research Institution or University   From / To   Duties / Responsibilities    
         
         
         
         

E. LANGUAGES

F. PREVIOUS FELLOWSHIPS

 List previously held fellowships from other organizations:
      Organization              From / To            Research 
         
         
         
         

G. OTHER AWARDS

  Yes     No 
 If yes, please give details below :
 

H. AREA OF RESEARCH IN WHICH YOU WISH TO BE INVOLVED (Proposal may be attached) :

I. BUDGET REQUEST (25 Baht = US$ 1)

 Salary  (maximum 300,000 Baht)
 Research Supplies  (maximum 100,000 Baht)
 Travel Plus Expenses  (maximum 50,000 Baht)

      1. Curriculum Vitae
      2. Evidence of continuation of present employment upon completion of fellowship


 Signature : _____________________________
 Date      : ___________