2022 Academy – Apply Now! – HERS East Africa

Fifth Academy Information

Fifth Academy Registration Form

Surname

Other Name(s)

Title

Nationality

Country of Residence

Marital Status

Address

Telephone Number (Including country code)

Expected Funder: Self/Employer/Other (Please specify)

Name of Institution

Position at Institution

Address

PhD Name

University

Date of Graduation

Master's Degree Name

University

Date of Graduation

Bachelor's Degree Name

University

Date of Graduation

Publications if any

Full Name

Professional Address

Phone Number

Email Address

Full Name

Professional Address

Phone Number

Email Address

Full Name

Professional Address

Phone Number

Email Address

Acceptance

I certify that the statements made by me to answer the foregoing questions are true and complete to the best of my knowledge. I understand that any misrepresentation or material omission made on this form may render my candidature null & void or lead to termination of Participation.