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ó÷àñíèêà ²²² Âñåóêðà¿íñüêîãî êîíêóðñó-çàõèñòó íàóêîâî-äîñë³äíèöüêèõ ⇐ ÏðåäûäóùàÿÑòð 4 èç 4
Ðîá³ò ó÷í³â-÷ëåí³â ÌÀÍ Óêðà¿íè Ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³ ó÷àñíèêà (ðîçá³ðëèâî)
Äîìàøíÿ àäðåñà: …………………………………………………………………………………..……………….. …………………………………………………………………………………………………… …………………………………………………………………………………………………… …………………………………………………………………………………………………… ……………………………………………………………………………………………………
³äîìîñò³ ïðî áàòüê³â: Áàòüêî: ……………………………………………………………………………………………. …………………………………………………………………………………………………….. …………………………………………………………………………………………………….. …………………………………………………………………………………………………….. (ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³, ì³ñöå ðîáîòè, ïîñàäà, êîíòàêòíèé òåëåôîí) Ìàòè: …………………………………………………………………………………………….. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. (ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³, ì³ñöå ðîáîòè, ïîñàäà, êîíòàêòíèé òåëåôîí) ̳ñöå íàâ÷àííÿ: ………………………………………………………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. (íàçâà, àäðåñà, Ï.².Á. äèðåêòîðà, òåë.ïðèéìàëüíî¿) Êëàñ/êóðñ………………………………………………………………………………………… ³ää³ëåííÿ ÌÀÍ………………………………………………………………………………… Ñåêö³ÿ……………………………………………………………………………………………. Áàçîâà äèñöèïë³íà………………………………………………………………………………. Íàçâà äîñë³äíèöüêî¿ ðîáîòè……………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Íàóêîâèé êåð³âíèê………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. (ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³, â÷åíèé ñòóï³íü, ïîñàäà, êîíòàêòíèé òåëåôîí) Ïîçàøê³ëüíèé çàêëàä, â ÿêîìó íàâ÷àºòåñü/íàâ÷àëèñü ……………………………………….. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. (íàçâà, àäðåñà, Ï ².Á. äèðåêòîðà, òåë.ïðèéìàëüíî¿) Ñê³ëüêè ðîê³â çàéìàºòåñü ó ÌÀÍ………………………………………………………………. ……………………………………………………………………………………………………. ª êàíäèäàòîì â ÷ëåíè ÌÀÍ/ä³éñíèì ÷ëåíîì ÌÀÍ…………………………………………. ……………………………………………………………………………………………………. ×èì îáóìîâëåíèé Âàø âèá³ð íàïðÿìêó íàóêîâîãî äîñë³äæåííÿ……………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ×è áóëè ïåðåìîæöåì/ó÷àñíèêîì ³íøèõ êîíêóðñ³â, îë³ìï³àä, çìàãàíü (ïåðåðàõóâàòè)…… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ×è âîëî䳺òå ³íîçåìíîþ ìîâîþ (ÿêîþ, ð³âåíü âîëîä³ííÿ)…………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ×è ìàºòå çàêîðäîííèé ïàñïîðò (äèòÿ÷èé ïðî¿çíèé äîêóìåíò) ……………………………… ……………………………………………………………………………………………………. Ñôåðà ³íòåðåñ³â …………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Ó ÿêèõ âèùèõ íàâ÷àëüíèõ çàêëàäàõ Âè ìð³ºòå çäîáóòè îñâ³òó……………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ßêîþ á ïðîôåñ³ºþ õîò³ëè á âîëîä³òè ………………………………………………………….. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Ó ÿê³é ñôåð³ Âè õîò³ëè á ðåàë³çóâàòè ñåáå ó ìàéáóòíüîìó (ïîë³òèêà, íàóêà, á³çíåñ, ³íøå) ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Âàø óëþáëåíèé ïèñüìåííèê ………………………………………………………………….. õóäîæíèê ……………………………………………………………………………….. àðòèñò…………………………………………………………………………………… ñï³âàê……………………………………………………………………………………. ñïîðòñìåí………………………………………………………………………………. Õòî º íàéá³ëüøèì àâòîðèòåòîì äëÿ Âàñ: ²ñòîðè÷íèé äåðæàâíèé ä³ÿ÷ Óêðà¿íè…………………………………………………………. ñâ³òó……………………………………………………………… Äåðæàâíèé ä³ÿ÷ ñó÷àñíîñò³ â Óêðà¿í³…………………………………………………………. ó ñâ³ò³ …………………………………………………………… ³äîìèé â÷åíèé Óêðà¿íè………………………………………………………………………. ñâ³òó…………………………………………………………………………. Ç êèì ³ç ñó÷àñíèõ â³äîìèõ îñîáèñòîñòåé Óêðà¿íè Âè õîò³ëè á ïîñï³ëêóâàòèñÿ: Äåðæàâí³ ä³ÿ÷³…………………………………………………………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Ïîë³òèêè…………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Íàóêîâö³…………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ijÿ÷³ êóëüòóðè…………………………………………………………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Ñïîðòñìåíè……………………………………………………………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ²íø³………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ϳä ÷àñ ïåðåáóâàííÿ ó Êèºâ³ Âè õîò³ëè á â³äâ³äàòè (âêàçàòè íàçâè): ²ñòîðè÷í³ ïàì’ÿòêè …………………………………………………………………………….. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Ìóçå¿ ……………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Òåàòðè……………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ²íøå …………………………………………………………………………………………….. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ßê³ ïîáàæàííÿ Âè ìàºòå ùîäî ä³ÿëüíîñò³ ÌÀÍ òà ïðîöåäóðè ïðîâåäåííÿ êîíêóðñó-çàõèñòó íàóêîâî-äîñë³äíèöüêèõ ðîá³ò …………………………………………………………………………………………………… …………………………………………………………………………………………………… ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. ……………………………………………………………………………………………………. Äîäàòîê 11 äî íàêàçó Ãîëîâíîãî óïðàâë³ííÿ îñâ³òè ³ íàóêè îáëäåðæàäì³í³ñòðàö³¿ __________________ ¹_________
ÏÀÑÏÎÐÒ
Íàçâà åêñïîíàòó (ðîçðîáêè)____________________________________________________ _____________________________________________________________________________ Ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³ àâòîðà ðîáîòè_______________________________________ _____________________________________________________________________________ Íàçâà çàêëàäó îñâ³òè, êëàñ (êóðñ), àäðåñà________________________________________ _____________________________________________________________________________ Ïð³çâèùå, ³ì’ÿ, ïî áàòüêîâ³ êåð³âíèêà ãóðòêà____________________________________ _____________________________________________________________________________ Íàçâà ãóðòêà; îðãàí³çàö³ÿ ÷è çàêëàä, íà áàç³ ÿêîãî ïðàöþº ãóðòîê, ïîøòîâà àäðåñà___ _____________________________________________________________________________ _____________________________________________________________________________ Âëàñíèê ðîçðàõóíêîâîãî ðàõóíêó, íàçâà áàíêó, êîä, ÌÔÎ ³ éîãî àäðåñà_____________ _____________________________________________________________________________ _____________________________________________________________________________ Îð³ºíòîâíà âàðò³ñòü åêñïîíàòó (ðîçðîáêè), âèçíà÷åíà êåð³âíèêîì ãóðòêà___________ _____________________________________________________________________________ ϳäïèñ äèðåêòîðà íàâ÷àëüíîãî çàêëàäó
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