THE POLISH ACADEMY OF SCIENCE

APPLICATION FOR A RESEARCH VISIT

country: 

PART  I 		PERSONAL DATA

1 Family name, first name, middle name (if any) and title:

 2 Date and place of birth, passport number:

3. Home address and telephone number:

4. Place of work in Poland (address, telephone and fax numbers, e-mail):

MEDICAL RESEARCH CENTRE PAS
PAWINSKIEGO 5, 02-106 WARSAW
TEL: (+4822) 6086488, FAX: (+4822) 6086527
e-mail: ..................@cmdik.pan.pl

5. Brief statement of scientific career including academic qualifications, posts held, 
research activities, etc. (max. 50 words): 

6. Field of specialization in brief: 

7. Main recent publications (to a maxim of 6)

PART II 			VISIT DETAILS

8. Dates and duration of visit (in days or weeks):

9. Place/s, names of institutions / laboratories and people to be visited, with dates/periods:

10. Are you acquainted with colleagues to be visited? Please enclose the letter of invitation). 

11. State purpose of a visit. In particular - will you (a) engage in research collaboration; (b) use a special facility or learn new techniques or both; (c) give lectures/seminars? (d) other. 
Please give details:

12. Outline of present research. Please give the title of joint research project (if any): 

13. Knowledge of relevant languages (fluent, adequate for conversation): 

14. Title/s of lecture/s offered together with details of visual aid equipment required:

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(signature of applicant) 								(date)