APPLICATION FOR AMT POGO FELLOWSHIP 2013

APPLICANT INFORMATION
1. APPLICANT INFORMATION
TITLE (Dr/Mr/Mrs/etc): Mr FIRST NAME(S): Giapril SURNAME: Doni
GENDER: Male Female NATIONALIT: In!onesia DATE OF "IRT#:
$OSITION:
INSTITUTION: $a!%a!%aran Uni&ersit'
MAILING ADDRESS ($ROFESSIONAL):
MAILING ADDRESS ($ERSONAL):
E(MAIL ADDRESS ($ROFESSIONAL): )iapril*!oni+,-)mail*com
E(MAIL ADDRESS ($ERSONAL):
TELE$#ONE: ,./0+/+11.2. FA3SIMILE:
Where did you hear about this fellowship? 4e5(site
2. SUPERVISOR AT APPLICANTS PARENT INSTITUTION
TITLE ($ro6/Dr/etc): FIRST NAME(S): SURNAME(S):
INSTITUTION:
MAILING ADDRESS:
E(MAIL ADDRESS:
TELE$#ONE: FA3SIMILE:
Has a letter of recommendation from the supervisor been attached and the original sent by post?
es No
3. PROSPECTIVE SUPERVISOR AT HOST INSTITUTION
Select from the drop-down menu:
S7per&isor
Is a letter of acceptance from the prospective host supervisor attached?
es No
POO-!"# $ellowship !pplication %&'%

4. FELLOWSHIP PROPOSAL
4.1. Title of proposed project
phytop!"#to"
4.2. Background: describe the wor( you are currently doing and what are your training
re)uirements*
$o%!&'"'$(%! ')("t'$'*!t'o"
4.3. Fellowship proposal: describe the pro+ect,training you would li(e to underta(e as part of the
fellowship- how this will benefit your current and future research- and any future collaborations
that might result from the fellowship*

4.4. Contribution to sustained capacity building at the parent institution: describe how you
intend to apply your s(ills and transfer your (nowledge to your peers when you return from
the fellowship. if you are not currently based in your home country- specify when you intend
to return and if you have a +ob to return to*

+. CURRICULUM VITAE
/riefly highlight your academic )ualifications and professional e0perience relevant to the training-
your current position,responsibilities and career aspirations*

,. PRACTICAL -ETAILS
Estimate! cost o6 econom' ret7rn international air tra&el 6rom parent co7ntr' to 8ost instit7tion:
EUR
9o7l! 'o7 re:7ire a &isa 6or t8e propose! &isit; es No
POO-!"# $ellowship !pplication %&'%