UW/MU – komitéen ved Universitetet i Bergen. 
Skjemaet fylles ut og sendes fra fakultetet til 
Forsknings og innovasjonsavdelingen og Annette
Kathinka Servan i Ephorte (sak 2022/17247)	

STAFF EXCHANGE PROGRAMME 2022/2023

This is an application for participation in the programme with:		UNIVERSITY OF WASHINGTON

	MEMORIAL UNIVERSITY OF  	
                                                                                    NEWFOUNDLAND

Semester preference:		2022:  Winter	 Spring	 Fall

	2023:  Winter	 Spring

	Other :	Specify:     	

PERSONAL DATA: 
Surname:      	First name:      	Date of birth:      

Home Address	:     	Telephone no.:     	Gender:

	Male 	Female	

Department:     	Tel/Fax no:     	E-mail:     	

Nationality:     		Marital Status:

	Married 	Single	

If you plan to bring your family, please give details: 
Name:     	Age:     	Relations:     	

Type of housing required:     	

ACADEMIC AND PROFESSIONAL BACKGROUND: 
Academic record:     	Date:     	Degree:     	Institution:      

	

Professional appointments:
(start with present position)
     

Please enclose your c.v.	Title:     	Period held:     	Employer:     	

PREVIOUS SCHOLARSHIPS AWARDED AND RESEARCH EXPERIENCE ABROAD
Dates:     	Type of scholarship or experience:     	Place and purpose:      	

PRESENT RESEARCH 
Give a brief description of your present research
     

	

AIM OF VISIT: 
Describe in detail your proposed research at the receiving university
(also include names of previous and anticipated personal contacts and department affiliation, if any)
     

	

Please enclose a list of your publications and participation in research projects including a letter of invitation and name of the contact person at the UW/MU.	

FOR OFFICIAL USE:
Recommendation from the department/office:     
	
Recommendation from the faculty:     
	
Important: the application will not be processed without recommendations	

Date and place:     	Signature: