| 1. |
Personal details |
| 1.1 |
Last (family) name |
| 1.2 |
First name(s) |
| 1.3 |
Title(s) |
| 1.4 |
Gender
|
1.5
|
Nationality |
| 1.6 |
Age, date and place of birth |
| 1.7 |
Marital status, number of children |
| 1.8 |
Private address and telephone |
| 1.9 |
Work address, telephone, telefax |
1.10
|
E-mail(s) for contact |
|
|
| 2. |
Scientific education |
| 2.1 |
University entrance qualification or high school-leaving exam certificate (e.g. “Abitur”, A-levels) including date, place, mark |
| 2.2 |
University studies (dates, universities, subjects, practical training, holiday courses etc.) |
| 2.3 |
Intermediate and final examinations (dates, universities, marks) |
| 2.4 |
Undergraduate support (e.g. fellowships) including dates, institutions |
|
|
| 3. |
Non-scientific activities |
| 3.1 |
Military service or community service, maternity or paternity leaves (dates) |
| 3.2 |
Vocational (i.e. professional) training (dates, description) |
| 3.3 |
Employment (dates, description) |
|
|
| 4. |
Planned MD thesis project |
| 4.1 |
Title of MD thesis project |
| 4.2 |
Location of project (university, institute) |
| 4.3 |
Supervisor of research work |
| 4.4 |
Official supervisor at home institution |
| 4.5 |
Commencement of project |
| 4.6 |
Anticipated commencement of MD fellowship |
| 4.7 |
Duration of fellowship applied for |
|
|
| 5. |
Financial circumstances |
| 5.1 |
Applications submitted to other promoting institutions |
| 5.2 |
Income of applicant (net per month, duration) |
|
|
| 6. |
Description of MD thesis project |
| 6.1 |
Title of MD thesis project |
| 6.2 |
Summary of project |
| 6.3 |
Detailed presentation of project: formulation of the problem, current status of research, applicant's own groundwork (if applicable), objectives, methods of investigation, bibliographical references |
| 6.4 |
Reasons for wishing to work in this particular laboratory |
|
|
| 7. |
Source |
|
Where did you first find out about the Boehringer Ingelheim Fonds (e.g. personal recommendation of supervisor or B.I.F. fellow; internet, article in journals, meetings, scholarship reference books, other sources) |
|
|
| 8. |
Additional documents to accompany your application(Xerox, photocopies) |
| 8.1 |
High school-leaving exam certificate or university entrance qualification |
| 8.2 |
Certificates of the intermediate examination in medicine (Physikum) and subsequent study achievements |
| 8.3 |
Letter of recommendation from the official supervisor of the MD thesis |
| 8.4 |
Letter of recommendation and of acceptance from the scientific supervisor at the host institute |
| 8.5 |
Official confirmation that the applicant will interrupt his/her studies and clinical activities for the duration of the fellowship |
