8/12/2019 Personal Questionnaire Fellowships Research Experience IIEN

1/4

PERSONAL QUESTIONNAIRE OF

JOZEF MIANOWSKI FUND A FOUNDATION FOR THE PROMOTION OF

SCIENCE

to apply for prora!

FELLOWSHIPS RESEARCH & EXPERIENCE II

PERSONAL DATA

Surname and FirstName

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Photo

Date and pa!e "#$irt%

""""""""" # """"""""" # """""""""""""""""""""""""""""""""""""""" day month yearPlace

Citiens%ip """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

C"nta!t

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Home address"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Phone no. E-mail

Passp"rt data

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Passport series and number"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Issuance date (dd.mm.rr) Expirationdate (dd.mm.rr)

PROFESSIONAL EXPERIENCE

Current '"$

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of institution

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Addres

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Phone no.E-mail

P"st "!!upied """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

C"mpeted studiesand de(rees

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of academic institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Deree!ear obtained

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$

8/12/2019 Personal Questionnaire Fellowships Research Experience IIEN

2/4

Name of academic institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Deree!ear obtained

Pre)i"us '"$s

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Post occupiedDates of employment

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Post occupiedDates of employment

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of institution

""""""""""""""""""""""""""""""""""""""""""""""""""

""""""""""""""""""""""""""""""""""""""""""""""" Post occupiedDates of employment

Pr"#essi"na*s!ienti+! s!%"ars%ips

"$tained

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of scholarship"institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #ountryDates of stay

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of scholarship"institution

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

#ountryDates of stay

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of scholarship"institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #ountryDates of stay

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of scholarship"institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #ountry

Dates of stay

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of scholarship"institution

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" #ountry

Dates of stay

SCHOLARSHIPS INFOR,ATIONS

Purp"se "# intentedsta-

%

8/12/2019 Personal Questionnaire Fellowships Research Experience IIEN

3/4

Pro$ect title

T%e panned pa!e"# t%e

s!ienti+!*resear!%s!%"ars%ip

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

Name of institution

T%e panned pa!e

"# t%e pr"#essi"nas!%"ars%ip

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""Name of institution

E.pe!ted peri"d "# sta-/Pease underine "ne

peri"d0

$&'($'%($)#$&'()'%($) (&'(%($)#(&'(*'%($) $&'()'%($& $&'(+'%($)

Expected period of stay of scienti%c"research scholarship

I f,lly ar-- ./t0 r-,lat/o12 r-ar3/1 240olar20/p ra1t2 o5-r-3 6y Jo7-f M/a1o.28/

F,13 A Fo,13at/o1 for Pro!ot/o1 of S4/-14- a13 4o!ply ./t0/t2 r,l-2'

I -9pr-22 0-r-6y !y 4o12-1t to pro4-22 a13 2tor- !y p-r2o1al 3ata 1--3-3 to 2-ttl-240olar20/p 4o!p-t/t/o1 a13 a44o!pl/20 for!al/t/-2 4o11-4t-3 ./t0 240olar20/p2

ra1t-3'

"""""""""""""""""""""""""""""""""

""""""""""""""""""""""""""""""""" Place& date 'inature

F""1in( atta!%ments must $e appied t" pers"na 2uesti"nnaire3

Characteristics of intended research project to be carried out in Poland, prepared in accordance

with the following points:

1. The main objective of the scholarship;

2. escribe the major area of !our interest within the conte"t of !our professional bac#ground

$. %ndicate a specific scientific center or host institution in Poland at which !ou would li#e to be

placed;

&. escribe the character of professional internship and t!pe of institution at which !ou would

li#e to be placed;

'. ("plain the importance of the project for !our:

) field

) home institution;

) home countr!;

) professional development;

one photo ; 2 recommendation for the candidate from recogni*ed scientific authorities +Polish andor

foreign-;

&

8/12/2019 Personal Questionnaire Fellowships Research Experience IIEN

4/4

T%e !"mpeted 2uesti"nnaire and atta!%ments s%"ud $e sent ee!tr"ni!a-

"# 4"e# ,ian"1s5i Fund 6 A F"undati"n #"r Pr"m"ti"n "# S!ie!e3

E7mai3 8a2a:!/a1o.28/'.a.'pl

Project Fellowships Research & Experience II is co-financed by Education for Deocracy

Foundation in fraes of !Re"ion in #ransition$ % RI# Pro"ra of the Polish-erican

Freedo Foundation'

)

mailto:kasa@mianowski.waw.plmailto:kasa@mianowski.waw.pl