Ton Hoek Scholarship for Young Leaders – Application

Please fill out the following fields and make sure you read the rules.
All fields marked with a * are required.

STEP 1

Date of birth *
Have you previously received any financial support, in any form, from the FIP Foundation for Education and Research?
Country: *

Other Country: *

STEP 2

Title:
First / Given Name(s):
Last / Family Name:
Gender:
FIP or IPSF Membership Number (if applicable) :
Professional occupation:
Street Address: *
Area code:
City: *
Region: *
Email: *
Telephone: *
Mobile:
Have you attended an FIP Congress before?
if yes, in which year(s):
Other planned and/or requested sources of support:
Curriculum Vitae (maximum 2 pages! pdf format):*  
Letter of presentation and motivation:* (pdf)  
First letter of recommendation:* (pdf)  
Second letter of recommendation: (pdf)*  
Proof of identity * (in pbf, png or pdf)  
Proof of registration/enrolment in a college or faculty of pharmacy (for undergraduate or postgraduate students), or residency program or professional organisation, or any certification of current professional or academic * (in pdf)  
A good quality photo: (jpg/png) *  
Signature
By signing this application the applicant agrees and understands that any monies received or paid as a result of this application are subject to the following terms:
  1. All information contained in this application is truthful and accurate to the best of your knowledge, and no relevant information has been withheld.
  2. Funds granted as a result of this request are expended for the attendance of the Annual FIP Congress as described in this application.
  3. The International Pharmaceutical Federation and the FIP Foundation for Education and Research have the right to make available and to use all data provided in this form for the purposes of managing the grant and to publicize the outcomes of the project.
  4. The applicant is obliged to keep the International Pharmaceutical Federation and the FIP Foundation for Education and Research informed about of any changes concerning the proposed application in a timely manner.
  5. In the event of winning the scholarship, the applicant is obliged to submit a final report as described in the guidelines.
Applicant’s name: *
Place: *
Date:
Signature: *
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I affirm that this application for a Ton Hoek scholarship for young leaders is original and has been independently developed by the author. I further affirm that I have read and understood the rules of the competition. rules of the competition.