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Formulaire d'inscription ROARES

  1. 1. Réseau Ouest Africain de Recherche pour la Santé West African Health Research Network Rede Oeste Africana de Pesquisa para a Saúde DEMANDE DE BOURSE POUR MOBILITE JEUNES SCIENTIFIQUES Veuillez remplir et signer ce formulaire et de l’envoyer au Secrétariat Exécutif du ROARES, 2006, Avenue Mamadou KONATE, 01 BP 390 Bobo-Dioulasso 01, Burkina Faso. E-mail : secretariat.wahrnet@gmail.com, site web : www.wahrnet.org Pour être recevables, les demandes doivent parvenir au ROARES au plus tard le 20 Mars 2014. 1. Nom de famille : __________________________ 2. Prénom : _____________________________ 3. Date de naissance :_________________________ 4. Sexe : M /F 5. Nationalité : ____________________________________ 6. Profession : ____________________________ 7. Adresse complète : __________________________________________________ _____________________________________________________________ _____________________________________________________________ Tel: _____________________________________ Fax: __________________________________ E-mail : ________________________________________________________________________ 8. Etudes universitaires : Institution : Dates : Niveau/Diplômes : ________________________________ ____________ _____________________________ ________________________________ ____________ _____________________________ ________________________________ ____________ _____________________________ 9. Recherches déjà effectuées : ___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ___________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Les formulaires de demande de bourse pour mobilité Jeunes Scientifiques sont disponibles auprès du : Secrétariat Exécutif du ROARES, 2006, Avenue Mamadou KONATE, 01 BP 390 Bobo-Dioulasso 01, Burkina Faso. E-mail : secretariat.wahrnet@gmail.com, et sur Internet : http://www.wahrnet.org
  2. 2. Réseau Ouest Africain de Recherche pour la Santé West African Health Research Network Rede Oeste Africana de Pesquisa para a Saúde 10. Institution(s) de recherche souhaitée (s) : ______________________________________________________________________________ ______________________________________________________________________________ ______________________ _____________________________________________________ (Date) (Signature du/de la candidat(e)) Les formulaires de demande de bourse pour mobilité Jeunes Scientifiques sont disponibles auprès du : Secrétariat Exécutif du ROARES, 2006, Avenue Mamadou KONATE, 01 BP 390 Bobo-Dioulasso 01, Burkina Faso. E-mail : secretariat.wahrnet@gmail.com, et sur Internet : http://www.wahrnet.org

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