Slavic Research Center

Slavic-Eurasian Research Center Hokkaido University Kita-9, Nishi-7, Kita-ku, Sapporo 060-0809, Japan Tel.: 011-706-2388 Fax: 011-706-4952 E-mail: [email protected] Foreign Visitors Fellowship Program Application Form 2018-2019

A complete and accurate response will facilitate our review. Please type or print, and fill in all blanks. Substitution of information with your vita is not acceptable. 1.Name in full: ______(Surname) (First or given name) (Middle name)

2.Present address: Home: ______Tel.: Fax.: E-mail: Office: ______Tel.: Fax.: E-mail: Please indicate which address you prefer to use in our correspondence: Home / Office 3.Date of birth: ______(Day) (Month) (Year) Place of birth:______(City) (Country)

4.Citizenship:

5.Have you ever applied to this fellowship program before? Yes / No If yes, in what years?

6.Present affiliation and status

Affiliation or place of work:

Status:

7. Highest academic degree you have acquired: (If Russian degrees, please specify them by Russian names such as kandidat or doktor nauk) ______(Type of degree) (Name of degree-granting institution) (Year) 8. Discipline and field of specialization: (a) Scientific discipline (history, political science, geography etc.):

(b) Field of specialization (e.g. 19th century Russian history, political participation in Poland, economic geography of the CIS, etc.):

9. Recent subject of research:

10. Title and a brief description of the project you wish to undertake at the SRC: (a) Title

(b) Description of your project (c) Your plan of collaboration with researchers and scholars in Japan (including the SRC staff members) (d) Your plan of contributing an article to the Center’s international refereed journal Acta Slavica Iaponica.

*As for your project description and plans, please write on separate pieces of paper (no more than 1,000 words) and attach it to this application form.

11._Education and academic training (Please specify in chronological order, giving all essential dates, beginning with graduation from university and ending with the highest degree): 12._Professional career (Please specify in chronological order, beginning with the present, giving all essential dates):

13.______Publications / Writings (10 items of books, articles, and other writings with complete publication data in the languages which they were originally published, together with their translation into English): 14._Please cite any academic honors received, including major fellowships or other awards:

15.______Names of persons whom you asked to write letters of reference:

______

______(Name) (Status) (Affiliation)

16. If accepted, which period of stay do you prefer?

From, , to (Day /Month/year) (Day / Month/ year)

17.______Languages (a) What language would you use at the SRC? (b) In what language would you contribute an article to Acta Slavica Iaponica? (c) In what other relevant languages are you proficient?

18.______Have you ever been to Japan? Yes / No If yes, when?

19. Will you be accompanied by your family member(s) to Sapporo? Yes / No If yes, who do you intend to take with you? (For example, wife and son)

* * * I declare herewith that the above is true and correct to the best of my knowledge.

______(Place) (Date) (Signature)