QUESTIONNAIRE

	Space
for
photograph	
1.	Surname				
	Given name				

2. Date, month, year and place of birth
(place of residence, region, republic, country)		
3. Citizenship (if you have citizenship of another state, indicate the state and date of receipt of citizenship)		
4. Education (when and which educational institutions you graduated from, registration numbers of diplomas)
Profession by diploma 
Qualification by diploma		
5. Postgraduate professional education: 
postgraduate study, postgraduate training programme, doctorate (name of educational or scientific institution, year of graduation) 
Academic degree, academic title (when was awarded, numbers of diplomas, certificates)		
6. Knowledge of languages:
a) native language 	
b) foreign languages in which you can:
read 	
write 	
speak 	

7. Information about previous employment:
The name of the previous employer should be indicated as was true at the moment of recruitment.
Month and year
of employment	Position held, institution, organization, enterprise as well as of affiliation to ministry (agency)	Location of institution, organization, enterprise	
commence-ment	termina-
tion			

				

				

				

8. Publications (list the main ones, indicating where and when they were published, attach a list for other publications):

9. National awards, other awards and distinctions, including those of the Russian Federation (name of award, date of its presentation by documents):

10. Memberships in Academies and other scientific societies and organizations:

11. Your current research interests (in particular, in which area of research or on which scientific themes you would like to work at JINR):

12. Family status: 

13. Your close relatives (father, mother, brothers, sisters and children), your husband (wife):
Degree of relationship	Surname,
given name	Year, date, month and place of birth	Place of work (name and address of organization, position held)	Home address (address of registration or actual residence)	

					

					

					

14. Members of your family who will arrive and reside with you during you work at JINR; their date, month, year of birth, and passport data:

15. Home address (address of registration or of actual residence), telephone number, e-mail address:

16. Passport (must be valid at least six months after the expiry date of your Russian visa):

(passport number, issuing authority, date of issue)

17. Your health condition:

18. Date of commencement of work and expected period of employment at JINR:

19. Other personal information you wish to provide:

“		”		20		Signature		
(Date of completing the Questionnaire)
Seal of the JINR Personnel Department	The photograph, the data about employment and education of the Applicant are in full compliance with the identification documents.	
	Stamp
“		”		20					
			(Date)				(Signature, name of Personnel Officer)	

Note
Please attach to the Questionnaire:
– a photocopy of the diploma of higher education, academic degree or title
– a photocopy of the passport (must be the original size of the passport, all the data must be legible, the passport holder’s photograph on the copy must be distinct).