ࡱ> c bjbj Yff n!  UU8}<9Op1'1'1';;;;;;;$>eA^;1'&&@1'1';UU2 ;O+O+O+1'RUU8;O+1';O+O+R4 60.KL'5|;;0<5fA(A< 6 6A 6\1'1'O+1'1'1'1'1';;)1'1'1'<1'1'1'1'A1'1'1'1'1'1'1'1'1' :  ANNEX 6a EMPOLLEX APPLICATION FORMPart A INFORMATION OF A PERSONAL NATURE (Part A and Part B must be completed by the Applicant, who should sign the form and send it to the National Correspondent for EMPOLLEX who will then send it on to EMSA) SurnameFirst NameNationalityDate of birthSex Private addressStreet and Nr.City, CountryPost codePhoneEmail Airport/rail station you would like to travel from Work addressInstitution & positionStreet and Nr.City, CountryPost codePhoneFaxEmailWeb site InsuranceAre you insured by your institution or by another source for participating in this Empollex exchange?YES / NO Knowledge of languagesPoorSufficientExcellentEnglishOther:Other: Part B INFORMATION CONCERNING THE EXCHANGE Your field(s) of activity Your expertise  General Motivation / Reason(s) for applying (please give as much detail as possible)  Your specific objectives for the exchange (please be clear and detailed)  Type of exchange requested (please refer to Annex 2 of the programme guidelines)Type 1 Single host approach ( Type 2 Multiple hosts approach: Several hosting centres in one country ( Hosting centres in more than one country (Type 3 Personal study approach ( Type 4 Group approach ( Comments  Preferred host institution(s) / organisation(s) (see Annex 7 of the programme guidelines) First choiceIf the multiple hosts approach is chosen above, please add additional hosting centres/countriesAndAndNameCity, CountryPhone/emailWebsiteContact name Second choice (if first choice is not available)NameCity, CountryPhone/emailWebsiteContact name Possible datesFirst choiceSecond choicePreferred duration of the exchange Undersigned Applicant, has taken note of and agrees with the rules & procedure for the exchange as described in the Empollex Guidelines and the Reimbursement Rules for Empollex ExpertsUndersigned National Correspondent recommends that the exchange proceeds according to the requirements aboveName: Date: Signature: Name: Date: Signature:  Any personal data included in or relating to this application is processed in accordance with Regulation (EU) No 2018/1725. Such data shall be processed solely for the purposes of the implementation of the EMPOLLEX Programme by EMSA as a data controller. The applicant or any other person whose personal data is processed by the data controller in relation to this application has specific rights as a data subject under Chapter III (Articles 14-25) of Regulation (EU) No 2018/1725, in particular the right to access, rectify or erase their personal data and the right to restrict or, where applicable, the right to object to processing or the right to data portability. Should the applicant or any other data subject whose personal data is processed in relation to this application have any queries concerning the processing of his/her personal data, this data subject shall address those to the data controller, to the Data Protection Officer of the data controller at:  HYPERLINK "mailto:DPO@emsa.europa.eu" DPO@emsa.europa.eu or lodge a complaint at any time to the European Data Protection Supervisor.     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