ࡱ> MOL AbjbjNN R0,w,w#$&&&P&'L0hO'O'e'e'e'(((0000000U24l0(((((0)e'e';0)))(^8e'e'0)(0))V.@x/\\& )v/ /000$/Tc5)c5x/)x/(((&& m:    Preliminary Application for Masters Degree Fellowships (Must be typed) NAME ___________________________________________ Male_____ Female_____ (As it appears in Vietnamese) Date of Birth (Day/Month/Year)________________Place of Birth: __________________ Present Position: __________________________________________________________ Current Employment at HSPH: ____________________________________________ __________________________________________________________________________ ___________________________________________________________________________ Institution Address: ________________________________________________________ ___________________________________________________________________________ Telephone (Office):________________________________ Fax _______________________ Home address:______________________________________________________________ ___________________________________________________________________________ Telephone (home): _________________ E-mail ___________________________________ Briefly describe your proposed field(s) of study: __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 2. Employment History (List positions held, beginning with most recent) NAME OF INSTITUTION POSITION DATES OF EMPLOYMENT (From/To) __________________________ _____________________ _____________________ __________________________ _____________________ _____________________ __________________________ _____________________ _____________________ __________________________ _____________________ _____________________ 3. Educational History (Include degree, non-degree, certificates and any other professional development workshops attended) Name of Institution Field of Study Date of Name of Degree/ Enrollment Certificate (In the Language Received)    4. Statement of Academic Purpose: In a statement of approximately 500 words, describe the focus of your proposed study. Explain how your academic training and your professional work experiences to date have prepared you for the proposed field of study. 5. If you have taken an English test (TOEFL/IELTS) provide the score and date taken: ____________________________________________ ____/_____/______ 7. Publications List below of any academic papers you have written or research activities you have conducted or participate. Papers or Research Activities Date 7.1. ______________________________________________ __________ 7.2. _______________________________________________ ___________ 7.3. _______________________________________________ ___________ 7.4. _______________________________________________ ___________ 8. Attachments Copies of original and English translation of all diplomas, transcripts. 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