Application form for Karolinska Institutet`s foundation grants Section

Last name, first name
Swedish person number
Application form for Karolinska Institutet’s foundation grants
Contents
Section A Financial need and/or academic qualifications ................................................................... 2
Section B Personal details and study circumstances ........................................................................... 2
1.
Personal details .................................................................................................................... 2
2.
Study circumstances ............................................................................................................ 2
Section C Foundations......................................................................................................................... 3
3.
Application for foundation grant ......................................................................................... 3
Section D Financial circumstances and personal letter ....................................................................... 4
4.
Family and housing circumstances ...................................................................................... 4
5.
Financial circumstances....................................................................................................... 4
6.
5.1
Limited student aid* .................................................................................................... 4
5.2
Estimated income in 2017 .......................................................................................... 4
5.3
Assets........................................................................................................................... 5
5.4
Debts............................................................................................................................ 5
5.5
Estimated total expenses in 2017................................................................................. 5
5.6
Summary of financial circumstances in 2017.............................................................. 5
Personal letter ...................................................................................................................... 6
Section E Academic qualifications...................................................................................................... 7
7.
Summary of research project ............................................................................................... 7
Fill out the form electronically, print it out, sign it and staple it together with the attachments.
1
Section A Financial need and/or academic qualifications
Mandatory for all applicants.
State whether your application is based on financial need and/or academic qualifications.
Financial need
Please note: Registered doctoral students
must arrange their support through the
responsible department. Thus, they are not
prioritised when assessing applications based
on financial need.
Academic qualifications
Academic qualifications refer to:
- An advanced study project for which a research plan has been drawn up
- Scholarly abstracts and publications
See announcement for information about eligibility.
Section B Personal details and study circumstances
Mandatory for all applicants.
1. Personal details
Don’t forget to fill in your name and Swedish person number at the top of page 1 as well
Last name, first name
Female
Male
Swedish person number
Citizenship, if not Swedish
Street address
Postal code, City
Phone no
E-mail address
Bank (name)
Account number
Clearing number
Account holder (if not the person above)
2. Study circumstances
Degree program
Number of completed semesters
Semester you were admitted to Karolinska Institutet
Pace of study (%)
Planned time for graduation
Are you planning to register for doctoral studies during 2016?
If you are planning an approved leave from studies within the next 12 months, state the reason and dates
Other information concerning your study circumstances
Transcript (studiemeritförteckning) from LADOK/KIDOK attached, mandatory for all applicants
Proof of registration (registreringsintyg) for autumn semester 2016 from LADOK/KIDOK attached, mandatory
for all applicants
Both certificates are available from LADOK (KIDOK) – please attach a signed original.
2
Section C Foundations
Mandatory for all applicants.
3. Application for foundation grant
To be able to match you with the correct foundation in the case of granting, please answer the following. Certificates that
verifies the specific eligibility are required.
Currently studying at the Study Program in Medicine (läkarprogrammet)*
YES
NO
Medical degree*
YES
NO
Currently studying histology at the Department of Neuroscience**
YES
NO
* Verified by the LADOK/KIDOK transcript, attached in section 2 above.
** Certificate from course leader at the Department of Neuroscience attached
3
Section D Financial circumstances and personal letter
Fill out this part if you are applying for financial reasons. If your application is based on academic qualifications only, please
go to Section D, page 7.
4. Family and housing circumstances
Are you living with a partner?
YES
NO
Children who are living with the applicant on a part-time or full-time basis – state their year of birth
Other information about family and housing circumstances
5. Financial circumstances
5.1 Limited student aid*
Limited student aid
If YES:
YES
NO
not entitled to student aid during
of remaining
If you are entitled to student aid but have not taken out a full student loan, explain why
semesters
* Student aid = student loan and/or student grant, the Swedish governmental financial aid for studies
(’studiemedel’) from the CSN Authority
Attachment, certificate from CSN – mandatory if you are not entitled to student aid
5.2 Estimated income in 2017
APPLICANT
PARTNER, SPOUSE
Student loans
Student loans
Student grant
Student grant
Income from employment after tax
Income from employment after tax
Other grants and scholarships
Other grants and scholarships
Interest and other income
Interest and other income
Housing allowance
Housing allowance
Other allowance (e.g. child allowance)
Other allowance (e.g. child allowance)
Other income
Other income
4
5.3 Assets
Saleable assets, such as stock, mutual funds, vehicles, etc. Apartments and real estate are NOT regarded as
saleable assets
APPLICANT
PARTNER, SPOUSE
Assets, please specify
Assets, please specify
Other information about assets
5.4 Debts
APPLICANT
PARTNER, SPOUSE
Student aid debt
Student aid debt
Other debts
Other debts
Debt payments
Debt payments
Interest
Interest
Other information about debts
5.5 Estimated total expenses of the household in 2017
Estimated total expenses of the household in 2017, please specify
If any of the expenses are specifically large, please explain why
5.6 Summary of financial circumstances of the household in 2017
Total income, including student loans
Total expenses
Total assets
Total debts
5
6. Personal letter
Fill out if you are applying for financial reasons.
No more than 3,000 characters.
I solemnly swear that the information I am submitting is complete and correct and that I
do not have any income, assets or debts other than those I have reported.
Signature of the applicant
Name in block letters
City, date
6
Section E Academic qualifications
Fill out only if the application is based on academic qualifications.
7. Summary of research project
Background, purpose, method, amount applied for and reason, timetable and any results achieved so far.
Can NOT be replaced by a research programme.
Maximum 3,000 characters.
List of any scholarly publications (including abstracts accepted by conferences)
Attachment – Recommendation from supervisor, signed original
Attachment – Statement from mentor representing the section or lab where the research is planned
to be performed, signed original
I have received previous scholarships based on academic qualifications
YES
NO
If YES:
which year(s)
Attachment, if YES above – a report that describes progress made since the previous scholarship award
I solemnly swear that the information I am submitting is complete and correct and that I
do not have any income, assets or debts other than those I have reported.
Signature of the applicant
Name in block letters
City, date
7