SCIENTIFIC COOPERATION BETWEEN PAN (POLAND) AND

F.R.S.-FNRS (THE WALLONIA-BRUSSELS FEDERATION OF BELGIUM)

______

APPLICATION FOR A STAY IN

POLAND (PAN)

Form to be completed by September 30th, 2015

Each application registered by the "Fonds de la Recherche Scientifique - FNRS" is followed by an acknowledgement of receipt.

Contact F.R.S.-FNRS : Contact PAN :

Tél. : 02 504 93 05 Tél. : +48 22 620 43 49

Fax : 02 504 92 92 Fax : +48 22 620 33 74

E-mail : E-mail :


SCIENTIFIC COOPERATION BETWEEN PAN (POLAND) AND

F.R.S.-FNRS (THE WALLONIA-BRUSSELS FEDERATION OF BELGIUM)

______

APPLICATION FOR A STAY IN POLAND (PAN)

1.  ADMINISTRATIVE DETAIL

Project title
Duration of the project: 2016 - 2018
Specific scientific field of research
1.1 The Wallonia-Brussels Federation of Belgium

Belgian coordinator of the project (Belgium)

Last name
First name(s)
Gender
/ Female o / Male o /
Date of birth
/ (DD/MM/YYYY) /
Nationality
Address at the university
University and department or laboratory
Street name and number / City and postal code
Phone / Fax
E-mail
Web site
Position / diplomas
Current position
University degree / Date of award
(DD/MM/YYYY)
List of the Belgian researchers participating to the project
Last name and first name(s)
/ /
University and current position
/
University degree
/ Date of award
(DD/MM/YYYY)
/
Last name and first name(s)
/ /
University and current position
/
University degree
/ Date of award
(DD/MM/YYYY)
/
Last name and first name(s)
/ /
University and current position
/
University degree
/ Date of award
(DD/MM/YYYY)
/
Last name and first name(s)
/ /
University and current position
/

University degree

/ Date of award

(DD/MM/YYYY)

/

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/
1.2. Partner country - Poland

Polish coordinator of the project (Poland)

Last name
First name(s)

Gender

/ Female o / Male o /

Date of birth

/ (DD/MM/YYYY) /

Nationality

Address at the university
University and department or laboratory
Street name and number / City and postal code
Phone / Fax
E-mail
Web site
Position / diplomas
Current position
University degree / Date of award
(DD/MM/YYYY)
List of the Polish researchers participating to the project

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/

Last name and first name(s)

/ /

University and current position

/

University degree

/ Date of award

(DD/MM/YYYY)

/
1.3. Account number of the Belgian university to which the payment should be made
Account number
Name and address of the university
Name and address of the bank
Communication

2.  DETAILED DESCRIPTION OF THE PROJECT (→ max. 3 pages)

2.1. Scientific objectives of the project.
2.2. Methodology / Working plan.
2.3. Expected results of the project.
2.4. Added-value of the collaboration for Belgium and Poland.
2.5. Financial resources from other sources of funding.
3.  CV OF APPLICANTS AND LETTER OF AUTHORIZATION
Please send the following documents by e-mail:
3.1.  curricula vitae of all researchers involved in the project (Belgians and Poles);
3.2.  letter of authorization of the Polish coordinator.
4.  MISSIONS OF BELGIAN RESEARCHERS
4.1.  Year 2016 (→ 1st year of the project)
From the Wallonia-Brussels Federation of Belgium to Poland.
Number of missions
Last name and first name(s) of
Belgian researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
4.2.  Year 2017 (→ 2nd year of the project)
From the Wallonia-Brussels Federation of Belgium to Poland.
Number of missions
Last name and first name(s) of
Belgian researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
4.3.  Year 2018 (→ 3rd year of the project)
From the Wallonia-Brussels Federation of Belgium to Poland.
Number of missions
Last name and first name(s) of
Belgian researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
5.  MISSIONS OF POLISH RESEARCHERS
5.1.  Year 2016 (→ 1st year of the project)
From Poland to the Wallonia-Brussels Federation of Belgium.
Number of missions
Last name and first name(s) of
Polish researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
5.2.  Year 2017 (→ 2nd year of the project)
From Poland to the Wallonia-Brussels Federation of Belgium.
Number of missions
Last name and first name(s) of
Polish researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
- 
5.3.  Year 2018 (→ 3rd year of the project)
From Poland to the Wallonia-Brussels Federation of Belgium.
Number of missions
Last name and first name(s) of Polish researchers / Length of stay / From
(DD/MM) / To
(DD/MM)
- 
- 
- 
- 
- 
- 
Date:
Signature of the coordinator of the project for the Wallonia-Brussels Federation of Belgium:

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