| MiCBT Scholarship for Researchers: Application

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Name*

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Date of Birth*

Email Address*

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Phone*

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Institution Affiliation (if any):

Number of years affiliated:

Name and email address of Referee or Supervisor:*

Regulating Body (if any):

Have you done any research before?*

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Qualifications:*

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List your academic honors, awards and membership activities:

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Relevant employment history: