LATVIJAS ZINĀTŅU AKADĒMIJA

Country to be visited

LATVIAN ACADEMY OF SCIENCES

Year

Exchange of scientists and specialists

APPLICATION FOR RESEARCH VISIT

Please
attach a
recent
photograph
(if possible)

Male Female

1.

Family name and first name

2.

Date of birth (Year, month, date) Place of birth

3.

Present citizenship

4. Home address and telephone, e-mail

5. Details about health insurance during the visit period

A. PROFESSIONAL DATA

1. Present position and field of specialization

2. Employer’s address and telephone (institute, university dept. etc.)

3. Education, university degree (include. year, place and field)

4. Short scientific biography and brief description of most important scientific work carried out up till now

5. Academic publications (3-5 - recent)

Knowledge of foreign languages

Fluent Average Fair

B. DETAILED RESEARCH /STUDY PROGRAMME

7. Proposed date of arrival and duration of stay

8. Purpose of visit

9. Description of subject to be studied

10.

Scientific institutions to be visited (address, telephone)	Name (s) of host scientist (s)	Period of stay

11. Have you had any previous contacts with the institutes above

12. Special requests, such as use of laboratory equipment, visit to scientific libraries etc.

Are you willing to give lectures? If so, please indicate title(s)

14. Will any member of your family accompany you at your own expense, who:

Date Signature

LATVIJAS ZINĀTŅU AKADĒMIJA ITALY

Zinatnu

2011-01-06

LZA