Анкета eng

Application form for the candidate of the title “Lviv Honorary Ambassador�

1. First and last name__________________________________________________ _____________________________________________________________________ 2. Education, including undergraduate, graduate and honorary academic titles _____________________________________________________________________ _____________________________________________________________________ 3. o o o o o o

Field of work: Science Politics IT Culture Business Other________________________________________________________

4. Achievements, scientific papers, publications and awards that are recognized on an international level _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 5. Place of work/occupation_____________________________________________ 6. Contact number____________________________________________________ 7. E-mail_____________________________________________________________ 8. Membership in professional, scientific and social associations _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________

9. List of international events (conferences, exhibitions, symposiums) which the candidate took part in during 2013-2015 (if there are more than ten please choose the most important) â„–

Name of the event

Date of the event

Place of the event

Role of the candidate in the event

1 2 3 4 5 6 7 8 9 1 0

10. List of events (conferences, exhibitions, symposiums) which the candidate organized or in which the candidate played a leadership role (e.g. speaker, facilitator) during 2010-2015 â„–

1 2 3 4 5 6 7 8 9 10

Name of the event

Date of the event

Place of the event

Web site

Number of participants

Role of the candidate in the event

11. List of events (conferences, exhibitions, symposiums) which the candidate is planning to hold in Lviv during 2015-2017 №

Name of the event

Date of the event

Place of the event

Role of the candidate in the event

1 2 3 4 5

12. Any additional information about the candidate’s role in idea or information exchange within his/her field _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 13. Please supply two letters of reference with this application to support this candidate’s leadership and expertise.

Nominator information: First and last name_____________________________________________________ Field of work_________________________________________________________ Place of work/occupation_______________________________________________ Contact number_______________________________________________________ E-mail_______________________________________________________________

Please send your applications by the 25th of July to the following address: Lviv Convention Bureau, Development department, office 416 Lviv City Council, 79006 Lviv Contact us: Andriy Pavliv (+38032) 254 60 30 info@lvivconvention.com.ua lvivconvention.com.ua/