Application form

 

Application Form

Name……………………………………………………………………………………

Employment status (select the appropriate): researcher; unemployed on retirement (education background: ……………………………..); student (year and faculty …………………………………………………….

Academic degree (field of study), provide the year and name of institution issuing the degree ………………………………………………………………………………………………….

Date of birth…………………………………………………………………………..………….

Current workplace (Institute/Faculty/Department, University) …………………………………………………………..…………………………………………………

Workplace address …………..………………………………………………………………….

Telephone number…….………………………………………………………………………….

E-mail……..…………………………….……….………………………………………………….

Website (if applicable) ..………………………………………………………………..

Postal address……..……………………………………….…………………………..

I grant my consent to publishing the contact/address data on PTNCE website YES / NO

E-mail YES / NO

Website (if applicable) YES / NO (address: ……………………………………)

Main fields of interest (key words)

……..…………………………………………………………………………………………………..

……..…………………………………………………………………………………………………..

Recommenders (members of PTNCE)

1)..…………………………………………………………………………………………………..

2)..…………………………………………………………………………………………………..

Date ………………………… Signature………………………………………………………