Appendix F

Male/Female/Other *

Male

Female

Other

First names initials *

Full first Names as in passport *

Prefix

Surname *

Date of birth *

dd/mm/yyyy

Place of birth *

Country of birth *

Nationality *

Home address *

Postal code *

Town or City / Country *

Telephone *

private email address *

The PhD research is
taking/took place at the
Faculty of *

Institute *

Title of the PhD thesis *

I enclose a copy/scan of a *Dutch*
doctoral/master diplome or
Admission to the Graduate School *

The following (UHD) supervisor(s) have been appointed as PhD thesis supervisor(s):

Please use the full titles and initals (Prof.dr. A. Last name) (dr. A. Last name)

1st Supervisor *

Attached to Univ. or inst. *

2nd Supervisor

Attached to Univ. or inst.

3rd Supervisor

Attached to Univ. or inst.

* = Input is required

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