COST Cooperation

SHORT-TERM SCIENTIFIC MISSIONS
COST 837

A P P L I C A T I O N F O R M

For the attention of the chairperson of the STSM Committee of COST Action 837 :

Dr. Daniël van der Lelie,
Flemish Institute for Technological Research (VITO)
Boeretang 200
B2400 Mol, Belgium

Please complete using a typewriter or in BLOCK CAPITALS

FROM



Name :


First Names :


Organisation :





Street :


Town and Postcode :


Country :


Telephone :


Telefax :


E-mail address :

1. Description of candidate
(Curriculum vitae and, if available, list of publications to be attached)

1.1. I apply for the period from ________________ to _________________

1.2. COST Action and title :

Project Number or Working Group number and title (if any) :


1.3. Academic qualifications (Title, Degrees) :

1.4. Nationality :

1.5. Date of birth :

1.6. Present employer (if different from organisation above) :


2. Detailed Work Plan (to be attached)

3. Detailed estimation of the funding requested (to be attached)

• Amounts in Euro and national currency
• Amount requested from CEC : - travel costs, - subsistence allowance
• Indication of contribution from other sources (national and/or private)
• Indication of other previous CEC financial support or current requests to the CEC (COST or other Commisision activities)
  
  Details of bank account :

5. I enclose the “Acceptance by the Host Institution” of the work plan duly signed.

I would be pleased to provide further information if requested to do so.

I, the undersigned, declare that the information provided above and enclosed is, to the best of my knowledge, accurate and complete.


Date : ………………………… Signature : ……………………………