Research Application Form – Quantum Leap Africa

Program to Apply For*
Name
First Last
Other Names Preferred Name (User ID/E-Mail etc)
Gender
Country of Residence
Country of Citizenship*
Other Country
Proposed Research Program
Provide more details about Proposed Research Program
Topic Title*
Abstract (max 2000 characters)*
Expected outcomes (max 2000 character)*
Describe the type of infrastructure, equipment, or human resources required for the successful execution of the proposed research program. Kindly indicate whether these resources will be available to you
Required Research Infrastructure (max 2000 character)*
Proposed Start Date
Date Format: DD dash MM dash YYYY
Information on Ph.D
Date PhD degree received
Date Format: MM slash DD slash YYYY
Graduating Institution*
Title of PhD Thesis*
Summary of PhD Thesis*
Name of supervisors*
Please tell us more on your current profession and position
Current profession
Start date for current position
Date Format: MM slash DD slash YYYY
Institution of current position
Work History
Number of Previous work Institutions
Name of Institution 1*
Country of Institution 1*
Date of Entry*
Date Format: MM slash DD slash YYYY
End date
Date Format: MM slash DD slash YYYY
Description of responsibilities
Name of Institution 2*
Country of Institution 2*
Date of Entry*
Date Format: MM slash DD slash YYYY
End date
Date Format: MM slash DD slash YYYY
Description of responsibilities
Name of Institution 3*
Country of Institution 3*
Date of Entry*
Date Format: MM slash DD slash YYYY
End date
Date Format: MM slash DD slash YYYY
Description of responsibilities
Post-Secondary Information
Number of Previous Institutions
Name of Institution 1*
Country of Institution 1*
Date of Entry*
Date Format: MM slash DD slash YYYY
Date of Completion/Expected Graduation*
Date Format: MM slash DD slash YYYY
Area of Study (1)*
Thesis (1)
Degree Awarded
Name of Institution 2*
Country of Institution 2*
Date of Entry*
Date Format: MM slash DD slash YYYY
Date of Completion/Expected Graduation*
Date Format: MM slash DD slash YYYY
Area of Study (2)*
Thesis Topic
Degree Awarded
Name of Institution 3*
Country of Institution 3*
Date of Entry*
Date Format: MM slash DD slash YYYY
Date of Completion/Expected Graduation*
Date Format: MM slash DD slash YYYY
Area of Study (3)*
Thesis Topic
Degree Awarded
Contact Information
Email*
Enter Email Confirm Email
Phone*
Home Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Mailing Address (If Different From Home Address)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Files to Upload are CV, Research proposal, publication list and at least one recent publication
Note that all documents should be submitted in PDF format only
Submit your research proposal document here*
Curriculum Vitae*
Accepted file types: pdf.
Letter of motivation*
Accepted file types: pdf.
Publication list*
Drop files here or
Accepted file types: pdf.
Please submit a list of your publication(s) with accessible link.
Sample publication(s)*
Drop files here or
Accepted file types: pdf.
You can submit one to three of your publication
REFEREES
Please provide contact information for at least two referees.
Please provide contact information for at least two referees. Please notify your referees that you are submitting their names as part of this application as they will be contacted for letters of recommendation as part of the selection process. Number of Referees (min 2, max 5)
Reference #1
First Name*
Last Name*
Position*
E-mail (Referee 1)*
University/Organization*
Reference #2
First Name*
Last Name*
Position*
E-mail (Referee 2)*
University/Organization*
Reference #3
First Name
Last Name
Position
E-mail (Referee 3)
University/Organization
Reference #4
First Name
Last Name
Position
E-mail (Referee 4)
University/Organization
Reference #5
First Name
Last Name
Position
E-mail (Referee 5)
University/Organization
OTHER INFORMATION
Learning/Physical/Accessibility/Mobility Needs
Other Comments?

Reference #1

Reference #2

Reference #3

Reference #4

Reference #5