APPLICATION CONCERNING THE RECOGNITION OF A FOREIGN QUALIFICATION 201 . . (month) I hereby apply for the recognition of my qualification acquired abroad. I hereby produce the following data required for an objective assessment of my qualification: 1. PERSONAL DATA OF THE QUALIFICATION HOLDER Name, last name Previous name, last name (if changed) Gender female male Date of birth (year-month-day) Citizenship Republic of Lithuania Other _________________________________ E-mail: Tel. Residence address (street, house No., apartment No., region, city, State) 2. THE QUALIFICATION REQUESTED TO BE RECOGNISED Name of the qualification (in the original language, Latin alphabet) Diploma issue date Name of the institution which granted the doctoral degree in science (art) (in the original language, Latin alphabet) The State in which the qualification was acquired Actual location of the education (studies) institution (indicate the address) daytime Study form: evening distance full-time other_____________ correspondence external studies part-time Duration of the studies year, from -to) Title of the thesis (in the original and in the Lithuanian languages) Science (art) research field closest to the subject matter of the thesis Thesis defending date Have you previously applied concerning an assessment / recognition of your qualification in Lithuania? no yes_______________________________________________ date and the institution (enter) Notes 1/2 3. PURPOSE OF THE RECOGNITION Work Other (enter) 4. PREVIOUS EDUCATION (acquired prior to the qualification requested to be recognised, to be listed starting with the higher education) Name of the qualification (in the original language, Latin alphabet) Duration of the education (studies) (year - from - to) Name of the education (studies) institution (in the original language, Latin alphabet) Address of the education (studies) institution Education (studies) form Notes 5. DATA ON THE RESEARCH AND PEDAGOGICAL ACTIVITIES (not more than 10 past years) Date of the recruitment Date of the dismissal Name of the workplace Position 5. SUBMITTED DOCUMENTS A document certifying the acquired doctoral degree in science (art), or its certified copy Supplement to the diploma of doctor in science (art) (if any), or its certified copy Personal identity document or its certified copy List of research publications (printed or electronic version) Doctoral thesis (printed or electronic version) Notes 6. DATA ABOUT THE AUTHORISED PERSON (to be filled in in case the qualification holder is represented by a person authorised by the applicant to perform the actions related to the recognition of the qualifications) Name, last name E-mail Tel. Residence address (street, house No., apartment No., region, city, State) 2/2 7. REPRESENTATION APPLICANT‘S SIGNATURE Patvirtinu, kad: šioje paraiškoje pateikti duomenys yra teisingi, pateikti dokumentai yra autentiški ir išduoti man. I hereby confirm that: the information provided in this application is true and the submitted documentation is authentic and issued to me. I understand that provision of false information and/or submission of fraudulent documentation will influence the outcome of the recognition of my qualification and may be reported to the relevant competent authorities. žinau, kad neteisingų duomenų ir (ar) neautentiškų dokumentų pateikimas turės įtakos priimant sprendimą dėl kvalifikacijos akademinio pripažinimo ir, kad apie tokių duomenų ar dokumentų pateikimą gali būti pranešta kompetentingoms institucijoms. /signature/ /name, last name of the applicant/ 3/2