Form to be completed by September 30

(1)

SCIENTIFIC COOPERATION BETWEEN CONACYT (MEXICO) AND F.R.S.-FNRS (THE WALLONIA-BRUSSELS FEDERATION OF BELGIUM)

____________________________________________________________________________________

APPLICATION FOR A STAY IN MEXICO (CONACYT)

Form to be completed by September 30

^th

, 2014

Each application registered by the "Fonds de la Recherche Scientifique - FNRS" is followed by an acknowledgement of receipt.

Contact F.R.S.-FNRS : Contact CONACYT :

Tél. : 02 504 93 05 Tél. : +52 55 5322 1748

Fax : 02 504 92 92 Fax : +52 55 5322 7647

E-mail : [email protected] E-mail : [email protected]

(2)

SCIENTIFIC COOPERATION BETWEEN CONACYT (MEXICO) AND F.R.S.-FNRS (THE WALLONIA-BRUSSELS FEDERATION OF BELGIUM)

__________________________________________________________________________________________

APPLICATION FOR A STAY IN MEXICO (CONACYT)

1. ADMINISTRATIVE DETAIL

Project title

Duration of the project: 2015 - 2016

Specific scientific field of research

1.1 The Wallonia-Brussels Federation of Belgium

Belgian coordinator of the project (Belgium) Last name

First name(s)

Gender Female  Male  Date of birth (DD/MM/YYYY) Nationality

Address at the university University and department or laboratory

Street name and

number City and postal

code

Phone Fax

E-mail Web site

Position / diplomas Current position

University degree Date of award (DD/MM/YYYY)

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(3)

List of the Belgian researchers participating to the project

Last name and first name(s) University and current position

University degree Date of award

(DD/MM/YYYY)

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(4)

1.2. Partner country - Mexico

Mexican coordinator of the project (Mexico) Last name

First name(s)

Gender Female  Male  Date of birth (DD/MM/YYYY) Nationality Address at the university

University and department or laboratory

Street name and

number City and postal

code

Phone Fax

E-mail Web site

Position / diplomas Current position

University degree Date of award (DD/MM/YYYY)

List of the Mexican researchers participating to the project Last name and first name(s)

University and current position

(DD/MM/YYYY)

(DD/MM/YYYY) - 4 -

(5)

(DD/MM/YYYY)

1.3. Account number of the Belgian university to which the payment should be made

Account number

Name and address of the university Name and address of the bank Communication

2. DETAILED DESCRIPTION OF THE PROJECT

(→ max. 3 pages) 2.1. Scientific objectives of the project.

2.2. Methodology / Working plan.

2.3. Expected results of the project.

2.4. Added-value of the collaboration for Belgium and Mexico.

2.5. Financial resources from other sources of funding.

3. CV OF APPLICANTS AND LETTER OF AUTHORIZATION

Please send the following documents by e-mail:

3.1. curricula vitae of all researchers involved in the project (Belgians and Mexicans);

3.2. letter of authorization of the Mexican coordinator.

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4. MISSIONS OF BELGIAN RESEARCHERS 4.1. Year 2015 (→ 1

^st

year of the project)

From the Wallonia-Brussels Federation of Belgium to Mexico.

Number of missions

Last name and first name(s) of

Belgian researchers Length of stay From

(DD/MM) To

(DD/MM) -

- - - - -

4.2. Year 2016 (→ 2

^nd

year of the project)

From the Wallonia-Brussels Federation of Belgium to Mexico.

Belgian researchers Length of stay From

(DD/MM) To

(DD/MM) -

- - - - -

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5. MISSIONS OF MEXICAN RESEARCHERS 5.1. Year 2015 (→ 1

^st

year of the project)

From Mexico to the Wallonia-Brussels Federation of Belgium.

Mexican researchers Length of stay From

(DD/MM) To

(DD/MM) -

- - - - -

5.2. Year 2016 (→ 2

^nd

year of the project)

From Mexico to the Wallonia-Brussels Federation of Belgium.

Mexican researchers Length of stay From

(DD/MM) To

(DD/MM) -

- - - - -

Date:

Signature of the coordinator of the project for the Wallonia-Brussels Federation of Belgium:

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