Name: Email:
Gender: Male Female Date of Birth:
Are you affiliated to Malawi Cancer Consortium (MCC) grant? Yes No
Are you affiliated to Malawi HIV implementation Science (M-HIRST) grant? Yes No
Name and Address of Institution |
Nationality: __________________________________
Which of the following best describes your current academic rank:
Undergraduate Student Post-doctoral Researcher
Masters Student Junior Faculty
PhD Student Other (please specify):
List your academic/professional qualifications as of 1 December 2016:
| Qualification | Year obtained | Institution | Subject |
What is your main area of research currently: __________________________________________________________________________________________________________________________________________________________________________
Are you available on 25th to 27th January 2017? Yes No.
In the space below please provide a statement describing why you need the course and how attending the Introduction to Implementation Science Course will be of benefit to your research career.
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date: _____________________ Signature of applicant: ____________________________
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