IMEC APPLICATION FORM

Last name: _______________________________ (please print) Nationality: ______________________________ Place and country of birth ___________________ Native tongue: ____________________________ Present address (please print) (valid until ././20)

First name: ________________________________

Date of birth: _______________________________ Sex: male female

Permanent address (please print) (send mail here after date given at left)

___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________

Your marital status: single married Number of children: _________________________ yes no

Do you intend to marry before you come here? Will your spouse come with you? yes no

Phone number: _____________________________ E-mail address:______________________________

Have you previously applied for admission to IMEC?

yes

no

If yes, what status? _____________________________________________________________________ Your honors, prizes or major publications:___________________________________________________

Your extracurricular activities and accomplishments: ___________________________________________

Your teaching or professional experience including summer and term-time work. Give name of employer, dates and nature of work: re of work:

Other experience, including military, volunteer work, travel. Give dates and nature of work:

Will you apply for a grant to Imec?

yes

no

SECONDARY SCHOOL (chronological)

Period
From (dd/mm/yy) To (dd/mm/yy)

Name and address of the institution

Name of studies

Qualifications obtained

Grade/ results

ACADEMIC DATA (past studies or higher education)

Period
From (dd/mm/yy) To (dd/mm/yy)

Name and address of the institution

Name of studies

Language used

Qualifications obtained

Grade/ results

I include transcripts for the following colleges, universities and schools. (These transcripts should show all papers taken separately, the marks obtained and the maximum and minimum-passing marks. A rank in class, grade point average or percentage should also be given.)

If you have not yet completed your studies at the time you submit this application form, then you are requested to forward your examination results and the certificate or legalised copy of your diploma. If the transcripts are not in Dutch, French, German or English, a translation in one of the mentioned languages must be added. All the documents (copies of diplomas, list of marks, translations) must be authenticated by an authority of the applicant's country or by the authority of the educational institution that delivered them. List any papers, articles or books you have published, scientific work you have done or awards obtained (use separate sheet if necessary).

Knowledge of languages (mark the appropriate spaces) Comprehension Languages

very good good fair very good

Reading
good fair

Writing
very good good fair

Speaking
very good good fair

Referring to the topics listed in the brochure or on our website, make a list of subjects of your choice. Please give on a separate sheet a personal statement or a motivation for your main choice.

Test results: Please read the general information to determine which test results you need.

Test results year GRE verbal % below quant. % below analytical % below

Year TOEFL

score

I declare, upon my honor, that this information is correct and complete,

Date: ___________________

Signature: ________________________________

IMPORTANT REMARK
Please fill in your answers very carefully. Date and sign these forms and send them, together with certificates, copies of your diploma and personal statement to: IMEC attn. Katrien Brees Doctoral Research Program Kapeldreef 75 B-3001 Leuven Belgium Email: phd@imec.be

STATEMENT OF OBJECTIVES
Please read instructions carefully before you complete this form. Please give your reasons for wishing to do graduate work in the field you have chosen. Prepare your statement of objectives and goals in whatever form clearly presents your views. Include as far as you can, your particular interests, be they experimental, theoretical, or issue-oriented, and show how your background and IMEC's programs support these interests.

Signature:___________________________

Date: _______________________________

Address in full:___________________________________________________________________

EVALUATION FOR GRADUATE ADMISSION

Applicants name: ______________________________________________________________________ Evaluator's name: ________________________ Title: _________________________________________ Address: _______________________________ Date: _________________________________________ School or company: _______________________ Telephone number: _____________________________ In what capacity do you know the applicant? _________________________________________________ How long have you known the applicant? ___________________________________________________ How does this applicant compare with his or her peer group in academic ability? truly exceptional
equivalent to the very best you have known - a person who, in your experience, appears only every few years

outstanding well above average above average average below average inadequate opportunity to observe

comparable to best-in-class students top 25% demonstrated high ability able to complete work to the Ph.D. lower 50%

In your opinion, how will this student perform compared to other Ph.D. students ? truly exceptional
equivalent to the very best you have known - a person who, in your experience, appears only every few years

outstanding well above average above average average below average inadequate opportunity to observe

comparable to the best student in a current class top 25% demonstrated high ability able to complete work to the Ph.D. lower 50%

th

Please give the applicant's ranking in your department (e.g. 7 in 89) ______________________________

Personal evaluation of the applicant : What are the most striking qualities and areas for improvement ? Qualities:

Areas for improvement:

If the applicant's first language in not English, please evaluate her/his proficiency to read, write, and speak English

Evaluator's signature: _____________________________________________________________________

Evaluators: Please feel free to add information about your own educational and professional background if you feel that such information will enhance our understanding of your evaluation.

Please seal and sign the envelope.