SCHOLARSHIP APPLICATION FORM for the period October 1st, 2014 till September 30th, 2015 to be filled in or typed, in English or in French, in triplicate To submit January 15th 2014 at the latest. SIE Scholarship Dr. Suzanne Noël Scholarship

1. Presenting Union/Single Club
Name of Union Name of Club	Name of Single Club

2. Applicant’s Status
Soroptimist Starting year	Non-Soroptimist What is your connection to the club presenting you?

3. Personal Data
Full name (Family name, First names) ,
Date of birth	Place of birth (Country)
Marital Status	Children
Country of Citizenship (passport)
Permanent Address
Telephone/Mobile
E-mail

4. Purpose of Scholarship
1. Supporting women in profession undertaking continuing education within their present chosen profession/vocation; regardless of educational level or discipline. 2. Supporting women in profession undertaking a pending career change; regardless of educational level or discipline. 3. Supporting women from developing countries with an existing SIE Club, towards professional and/or vocational training. Dr.Suzanne Noël Fund: This fund aims at giving a financial help to a female doctor willing to perfect her knowledge and experiments regarding plastic and restoring surgery. Note: Preference might be given to applicants attending the last year of their studies or training courses.

5. CURRICULUM VITAE
Present occupation or employment Full-time Part-time Start (mm/yy):
Previous employments (last or 3 most relevant)
Job title	Employer	Full-time	Part-time	Dates (mm/yy) start - finish
-
-
-
Educational, professional / technical or other qualifications (degrees, diplomas, certificates, licenses, etc. where and when received) - no more than 3 most relevant
Qualification	Where received (Institute and Country)	When (mm/yy) - latest first
Other information (e.g. prizes, grants, articles, exhibitions) * See Appendix: InstRuctions and conditions
Languages spoken, only if relevant concerning this application (indicate proficiency) *See Appendix: InstRuctions and conditions

6. Programme of study or training for which the scholarship is requested
Study Programme/training Title:
Establishment/Institution where studies would be undertaken Name: Adresse: Website:
Candidate has been accepted: Yes (add document of acceptance) No If not, document of acceptance has to be sent no later than end of March 2014 to the Committee Chairperson.
Start and duration of the whole study programme/training: - (mm/yy - mm/yy) (give proof of ongoing studies/training)
Period to be covered by the SIE scholarship (maximum one year: 1st October 2014 - 30th September 2015) - (mm/yy - mm/yy)
Impact of study programme or training on you and how do you expect to use the newly gained experience and/or knowledge or the benefit of your career and the society?

7. Budget of the Study Programme/Training
Total costs of the studies/training in Euros for the period to be covered by the SIE scholarship * see Appendix: InstRuctions and conditions
Registration fees	€
Tuition fees	€
Housing, living expenses	€
Books, software, paper	€
Health and Insurance	€
Other costs(detailed)	€
Total NOTE: Costs which are not accepted Hardware (computer etc.) Travel costs between countries	€
What amount in Euros do you apply for (no more than 15 000 Euros)?	€
If you need more than the maximum amount of the Soroptimist scholarship to carry out your programme, how will you cover these costs?
Do you get other scholarships/grants? Period covered - (mm/yy - mm/yy) Amount Euros

8. Applicant Signature
I, the undersigned, hereby certify that all information given in this application is complete and accurate to the best of my knowledge. I have attached all required documents and have provided the necessary papers to be forwarded to the President of the sponsoring Soroptimist Club. I agree to all terms and conditions governing this scholarship/grant given in the Appendix: InstRuctions and conditions.
Applicant Signature	Date
The following documents belonging to the application need to be attached/enclosed: Applicant’s letter of presentation Recommendation by a professional person Recommendation by a Soroptimist of the nominating Club and/or by the President of this Club Document of acceptance Other documents (list):

9. Endorsement of Unions/Single Clubs
Union Endorsement
(Name of candidate) who has been proposed by the Club of (name of the Club) is presented as a candidate for a SIE scholarship by the Union of . The Union President or the Scholarship Committee Chairperson of the Union forwards this application to the SIE Scholarship Committee Chairperson 2013-2015: Mariana Abrantes de Sousa Rua Augusto J Cunha 5, RCB PT 1495-240 Algés PORTUGAL January 15th 2014 at the latest!!!
Name (Union President) (please print) E-mail:	Date
Signature
Name (Union Scholarship Committee Chair) (please print) E-mail:	Date
Signature
Club Endorsement
Name (President of sponsoring Club) (please print) E-mail:	Date
Signature

or

Single Club Endorsement
(Name of candidate) is presented as a candidate for a SIE scholarship by the Single Club of (Name of Single Club). The President of the Single Club forwards this application to the SIE Scholarship Committee Chairperson 2013-2015: Mariana Abrantes de Sousa Rua Augusto J Cunha 5, RCB PT 1495-240 Algés PORTUGAL January 15th 2014 at the latest!!!
Name (Single Club President) (please print) E-mail:	Date
Signature

SIE Scholarship Fund and Dr. Suzanne Noël Scholarship Fund

Appendix: INSTRUCTIONS and conditions for Applicants

General information

Use the Scholarship Application Form for the period 2014-2015.

The application must be typed in English or French.

The application must be transmitted, including all additional sheets, and other relevant documents, in triplicate and, as for the application form, electronically to the nominating Club President.

Questions must be answered fully.

Do not use abbreviations.

All certificates and recommendations in languages other than English or French must be accompanied by a translation.

Handling the electronic form:
- when using the electronic form, space will increase as you type;
- when printing a paper copy of the electronic form, increase the space before printing it;
- when typing on a printed form, if space is insufficient, attach supplementary sheets, write your name on every supplementary sheet, and indicate the subject.

Dr. Suzanne Noël Scholarship

CONDITIONS REQUIRED FROM THE CANDIDATE

To be under 50,

To be qualified to practise medicine,

To be already specialised in plastic surgery, if not, be preparing a thesis on plastic and restoring surgery,

To present a written certificate from a plastic surgeon, member of the association of surgeons specialized in plastic and restoring surgery from the country which presents the candidate

Curriculum vitae (5)

Other information: such as prizes, grants, publications, articles, exhibitions, videos, musical recordings, personal grants that are relevant for your study programme or training.

A language certificate, issued by a qualified person or institution, is needed if you wish to study in a country where the language is different from your own.

Budget (7)

All costs have to be documented. Give details of all fees. Other expenses have to be listed in detail as far as possible.

Signature (8)

The application has to include a short letter of presentation and CV.

An applicant needs a letter of recommendation from a member of her profession/vocation.

An applicant needs a letter of recommendation from a Soroptimist of the nominating Club and/or from the President of this Club.

Before signing your application, read the following conditions:

If granted a scholarship by Soroptimist International of Europe, I will:

inform myself about Soroptimist International,

be in contact with the nominating Soroptimist Club,

be ready to commence and proceed with my studies without undue delay, at the time stated on my programme, and in any case within the 1st of October 2014 when the grant was assigned, and the 30th of September 2015,

refund the sum received for the amount I did not utilise, as soon as possible, in case I become physically or otherwise unable to carry out my commitments, and

submit a final report to the nominating Club at the end of the study period and not later than December 31st 2015. (You will get the SIE Scholarship Final Report Form from the Club when granted).

agree to have my final report published, eventually with pictures, in “The Link” (quarterly periodical of SIE), on demand of the Scholarship Committee.