Application for Support by students from Bangladesh already registered or accepted for a Ph.D.

or equivalent course in a British University or recognised institution of higher education in the

UK.

1. Name

2. M/F .

3. Date of Birth.

4. Address in Bangladesh

5. Address in the UK (if applicable)

6. Tel no

7. Email address .

8. Details of educational qualifications

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9. UK Education Institution at which the applicant is registered for a post-graduate level course of
study (please send a copy of the registration document)

10. Course registered for

11. Topic of research (This is a key selection criterion. Please include as much detail as necessary or
submit a summary on a separate sheet.)

12. Current status of project / Expected date of completion

13. Name and contact address/ email of academic supervisor or contact within the UK educational
institution. A letter of support for your application from your academic supervisor is required

14. Purpose for which financial support is required

15. Estimated sum required (maximum 1,500) .................

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16. Details of scholarships received or applied for, and of other sources of financial support.
[Applicants will need to satisfy the Trustees that they will have access to sufficient funds from other
sources to enable them to complete their course.]

17. Proposed career on return to Bangladesh

Signed.
Date

Please send this completed form (preferably by e-mail) with additional material if desired to:
Tim Butchard, Secretary, The Charles Wallace Bangladesh Trust
4, Dorville Crescent, London W6 0HJ, The United Kingdom
E-mail: timbutchard@wallace-trusts.org.uk

March 2009

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