Author: arta
Last saved by: zibdamez
Company: Nordisk Informasjonskontor

| Nordic Council of Ministers | This form may be photocopied. Only one copy per project is to be sent in. For further information, see Invitation. Aug-95

Nordic Scholarship Scheme for 
the Baltic Countries and Northwest Russia

APPLICATION FORM 
Exchange of Civil Servants
APPLICATION DEADLINE: February 15, May 15, October 15, 2003 respectively 

This form may be completed in Danish, Norwegian, Swedish  or English. Please type or use block letters.
Mail to the Nordic Councile of Ministers Information Office in Riga, Marijas 13/3, LV-1666 Riga, Latvia

1. INDIVIDUAL APPLICANT
1. NAME  Family name | First name

2. DATE OF BIRTH:

    SOCIAL SECURITY NUMBER (if any)

3a. ACADEMIC TITLE:

3b. PROFESSIONAL TITLE:

4. SEX   

❑ Male

❑ Female

5. NATIONALITY
❑Estonian 	❑Lithuanian  	❑Latvian
❑Russian
❑Nordic ..............................................  (Specify) 

❑Other...................................................(Specify)

7a. NAME OF HOME INSTITUTION 
(where presently studying/employed)

6.  ADDRESS at home: | 7b.  ADDRESS at work:

Telephone:

Telephone                         	Telefax                                  

Telex			e-mail

7c.RECOMMENDATION FROM HOME INSTITUTION                              ❑ YES (documentation must be enclosed)
8. NAME OF HOST INSTITUTION (in visiting country):
9. ADDRESS:

Telephone                                 Telefax                                 e-mail

CONTACT ESTABLISHED
❑ YES (Letter(s) of invitation must be enclosed)

10. CONTACT PERSON AT THE HOST INSTITUTION (if any)
      Family name                                                       First name

11. PROFESSIONAL TITLE, ACADEMIC TITLE

12. FIELD OF STUDY

13. SUGGESTED DURATION OF STAY (weeks) in 
Denmark .................. Finland ................... Iceland .................. 
Norway..................  Sweden.................. 

❑ Estonia     ❑ Latvia     ❑ Lithuania        ❑ Russia

.......................................................................................................

14. SUGGESTED DATES OF ARRIVAL. List by order of priority. Please indicate if any of these dates have been previously agreed                                                                                                                                         with receiving institution:                                          1                                             2                                            3

15. PREVIOUS PROFESSIONAL VISITS IN HOST COUNTRY (if through a scholarship programme, please specify which):

16. EDUCATION AND PROFESSIONAL EXPERIENCE. 
      Education – specify degrees (highest first), university, year, and specialisation .
      Certified copies of degrees and records should accompany the application. DO NOT SEND ORIGINALS

Name of university or professional school

Major field of study

Name of degree or diploma
(In original language and translation)

Date received

On-going education:

Name of university or professional school

Major field of study

Name of degree or diploma
(In original language and translation)

Expected date to be finished

Professional experience (incl present employment) - give title, nature of work, employer and dates of employment.
Other qualifications

17. PURPOSE OF STAY IN HOST COUNTRY
     (Give a detailed plan for the study visit, travel route and estimated travel costs in Danish crowns (DKK), if necessary continue on a separate sheet.)

18. Financial support applied for/received from other sources		❑ YES		❑ NO
      If yes, state the applied/received sum as well as source:

19. KNOWLEDGE OF FOREIGN LANGUAGE AND PROFICIENCY IN EACH:
English | Other language (specify)....................................................
excellent  good   average   poor | excellent   good  average     poor
Understanding | | | | | | | Understanding | | | | |
Reading | | | | | | | Reading | | | | |
Speaking | | | | | | | Speaking | | | | |
Writing | | | | | | | Writing | | | | |

SIGNATURE:

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Place                                                                                       Date                                           Signature

II . APPLYING  INSTITUTION
20. NAME OF APPLYING  INSTITUTION
21. ADDRESS:

Telephone                             Telefax                             e-mail

CONTACT ESTABLISHED
   ❑YES, documentation must be enclosed

22. CONTACT PERSON AT THE  APPLYING INSTITUTION                                                                                                                                                                                                                      Family name                                                       First name | 23. PROFESSIONAL TITLE, ACADEMIC TITLE

24. DESCRIPTION OF PROJECT.  Give name, address and name and title of contact person of co-operating institution. 
      Describe  purpose and contents of activity; if necessary continue on a separate sheet.

PROJECT TITLE :

25. Financial support applied for/received from other sources		❑ YES		❑ NO
      If yes, state the applied/received sum as well as source:

SIGNATURE:

----------------------------------------------------------          -------------------------------       ----------------------------------------------------------------------
Place                                                                                       Date                                           Signature