PERSONAL QUESTIONNAIRE for PERSONS INTENDING

to APPLY for a SCHOLARSHIP from MIANOWSKI FUND

Address: MIANOWSKI FUND
00-330 WARSZAWA Paac Staszica, room 109a, Nowy wiat 72, tel.+48 22 826-71-74
Surname and First Name ...................................................................................................................................
Date and place of birth ......................................................................................................................................
Citizenship ........................................................................................................................................................
Home address ....................................................................................................................................................
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Profession, post occupied ..................................................................................................................................
Employer name, address ................................................................................................................................
Completed studies and degrees (name of academic institution, degree, when obtained) .................................
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Professional career (name of institution, post occupied, years) ........................................................................
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Membership of professional / academic organizations .....................................................................................
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Scholarships obtained and periods of research, etc., abroad stays (country, institution, dates of stay) ...........
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Contact with Polish institutions and / or Polish researchers .............................................................................
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Purpose of intended stay ...................................................................................................................................
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Name of Polish institution of intended stay / or Polish researchers ..................................................................
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Expected period of stay, date of arrival .............................................................................................................
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I fully agree with regulations regarding scholarship grants offered by MIANOWSKI FUND and comply with
its rules.
I express hereby my consent to process and store my personal data needed to settle scholarship competition
and accomplish formalities connected with scholarships granted.

Date ...............................................

Signature ............................................................

Applications submitted by persons concerned should bee accompanied by documents as follows:

- Curriculum Vitae;
- List of publications in the last five years;
- Characteristics of intended research projcet;
- Letter of recommendation from an institution or organization wishing to receive the candidate;
- Letters of two persons of renowned scientific/academic authority
- One photo.