APPLICATION FORMAT FORINDO- US PUBLIC HEALTH RESEARCH FELLOWSHIPS

Please Note: Application should not be more than 15 pages maximum including CVs

(Times New Roman, font size 12, single spaced) Application should be forwarded through the head of organization/

department where the applicant is employed. Applications should be emailed to public.health@indousstf.org in the

following two parts:

Part - I: To be sent by the Applicant

1. Name of the Applicant:

2. Designation:

3. Parent Indian Institution:

4. Date of birth & age (as on 28.02.2013):

5. Sex (Male/Female):

6. Nature of Employment:

7. Academic qualifications:

8. Details and nature of present and previous employment (Positions held, employer/place of work, duration, area/nature of work)

9. Honors and awards received:

10.Broad area of research:

11.Host institute in USA

12.Host person in USA

13.Contact address of the host person

14.Proposed duration of the fellowship (Months)

15. Essay on a research proposal of interest to you and how this fellowship would help with your career goals (not more than 2 pages)

16.Specific need for the joint work and expected outcomes

17.State any other relevant aspects in the application which may be useful for the reviewer to make a qualitative judgment on the application.

18.Details of international fellowships availed in the last three years:

S. No. Address of Duration Agency Brief Achievement/overseas institute which objective of Outcome

sponsored the workthe visit done

19. Details of applications made/ pending for any other international fellowships:

S. No. Address of Duration Agency Brief objective of the workoverseas institute done

20. Projects with applicant:

S. No. Title Grant Period Cost (Rs. in Fundinglakhs) Agency

21. List of publications/ papers presented in conferences during the last 5 years

22. Details of financial support sought from IUSSTF and committed support/fellowship from other sources

23. Brief CV of the applicant and the host US scientist (not more than 2 pages each)

24.Names of your referees

Part - II: Letters of Recommendation

Two recommendation letters are mandatory but a third letter is allowed.Please arrange for these recommendation letters to be sent directly by your referees by email to public.health@indousstf.org

Enclosures:(i) Scanned copy of acceptance letter from US host (Annexure-I) (ii) No-objection certificate from the current employer in India.

Annexure-I: Acceptance letter from US host

This form should be completed by the US Host

Name of the US Host

What facilities would be made available to the applicant for the fellowship at your institution?

How will this fellowship benefit your institution and/or the United States-India collaboration?

How will the applicant benefit from this fellowship?

I confirm that the applicant named above will be welcome to work in my research group.

Name:

Signed:

Date: