Department/Laboratory stamp	Warsaw, dated

REPORT ON STAY in 		

1.	Full name

2.	Place of work (Department/Laboratory)

3.	Place of stay abroad (name of institution, facility, address – in English)

4.	Duration of stay

5.	Purpose of travel

6.	Cooperation topic

7.	Results of visit

8.	Possibility of using the results of travel in the country

9.	Other benefits from travel

10.	Method of financing

signature of the Department/Laboratory Head		signature of the employee