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The Pemberley International Study Centre, Haputale, Sri Lanka
Pemberley House
Eligibility Information
Trustees/ Board

APPLICATION  FORM  FOR  RESIDENT   SCHOLARS
For a Tenure of up to Four Weeks, From 1 June - 31 August, each year

First Name       
Surname
Applicant's Position/ Title
Home Address
Business Address
Home Phone
Business Phone
Fax
E- Mail
Sex
Date of Birth
Citizenship
List Language(s) including native language in which you are able to converse fluently
Difficulty walking up hill
I do We do
l do not We do not
Will your spouse/ partner be accompanying you
Yes No
Name of Spouse/ Partner
Title of the Applicant's Project
Preferred Dates for residency
(please provide two alternatives in case your first choice is unavailable)

 
  1.  
  1.  
  1.  
Names and complete addresses, including postal codes, phone & fax numbers, and e-mail addresses, of 2 persons (no more than one from the same University or Institution) whom you have informed about your project, and who will write a reference for you. In your interest, contact your referees in advance to ensure they will write on your behalf.

Referee (1)
Name
Address
Phone
Fax
E-Mail
Referee (2)
Name
Address
Phone
Fax
E-Mail