求是科技基金会.doc

求是杰出青年学者奖申请表 Qiu Shi Outstanding Youth ScholarApplication Form 姓名 Name 中文 Chinese 性别 Gender 照片 Photo 英文 English 出生日期 Date of Birth 出生地 Place of Birth 国籍 Nationality 回国前单位及职务 Former Employer and Position in Foreign Country 任职年份 Time 拟任职单位名称 Current or Expected Employer 职务 Position 专业领域 Area of Specialty 专业方向 Professional Field 从事专业关键词 Keywords of Specialty 教育经历（从本科填起） Educational Experience (Start from Bachelor) 学位Degree 时间Time国家Country 院校University 专业Major 工作经历（兼职请注明） Work Experience (Please Footnote Part-time Positions) 职务Position 时间Time 国家Country 单位Employer 个人自传Biography (限1000字以内)  主要学术成果Academic Achievements 主要科研成果(Major research accomplishments) 重要获奖情况MajorAwards 获奖项目名称 Title of awarded project 奖励名称 Name of the Award 奖励等级 Award level 授奖单位及国别 Awarding Body and Country 获奖年度 Year 代表性著作及论文Representative publications 论著名称 Title 出版单位或期刊名称、期号；起止页码；所有著、作者姓名 Publication Date, Publication Media, Journal title, Page, Author  全职回国工作设想：包括回国后的主要研究方向和思路、工作目标、预期贡献，现有基础、团队和需要的支持等 Research Plan (as independent researcher in China)：Including proposed project(s), approach and rationale, expected outcome and significance, current career development and goals, researchteam, required support, etc. 请提供三位具资格对申请人作适当评价的推荐人信息，并说明与申请人关系 Please provide thenames and contactinformation of three referees who couldprovide confidential assessments regarding this applicant/application. Applicant must declare any specific relationship with referees, e.g. former supervisor, collaborator, etc. 姓名 Name 单位与职位 Position, Institution 与申请人关系 Relationship with Applicant 通讯地址 Address 电话 Phone 电邮 Email 申请人声明Declaration by the Applicant 本人以上信息均真实有效。本人郑重承诺：自获求是杰出青年学者奖的半年内全职到岗工作，在国内连续工作不少于三年。 I hereby declare that the information provided in this form is truthful and accurate to the