Application form

for the candidate of the title “Lviv Honorary Ambassador”

1. First and last name__________________________________________________

_____________________________________________________________________

2. Education, including undergraduate, graduate and honorary academic titles

_____________________________________________________________________

_____________________________________________________________________

3. Field of work:

o Science

o Politics

o IT

o Culture

o Business

o Other________________________________________________________

4. Achievements, scientific papers, publications and awards that are recognized

on an international level

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

5. Place of work/occupation_____________________________________________

6. Contact number____________________________________________________

7. E-mail_____________________________________________________________

8. Membership in professional, scientific and social associations

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

9. List of international events (conferences, exhibitions, symposiums) which the

candidate took part in during 2013-2015 (if there are more than ten please choose

the most important)

№ Name of the event Date of the

event

Place of the

event

Role of the

candidate in the

event

1

2

3

4

5

6

7

8

9

1

0

10. List of events (conferences, exhibitions, symposiums) which the candidate

organized or in which the candidate played a leadership role (e.g. speaker,

facilitator) during 2010-2015

№ Name of the

event

Date of

the event

Place of

the

event

Web site Number of

participants

Role of

the

candidate

in the

event

1

2

3

4

5

6

7

8

9

10

11. List of events (conferences, exhibitions, symposiums) which the candidate is

planning to hold in Lviv during 2015-2017

№ Name of the event Date of the

event

Place of the

event

Role of the

candidate in the

event

1

2

3

4

5

12. Any additional information about the candidate’s role in idea or information

exchange within his/her field

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

13. Please supply two letters of reference with this application to support this

candidate’s leadership and expertise.

Nominator information:

First and last name_____________________________________________________

Field of work_________________________________________________________

Place of work/occupation_______________________________________________

Contact number_______________________________________________________

E-mail_______________________________________________________________

Please send your applications by the 25th

of July to the following address:

Lviv Convention Bureau, Development department, office 416

Lviv City Council, 79006 Lviv

Contact us:

Andriy Pavliv

(+38032) 254 60 30

info@lvivconvention.com.ua

lvivconvention.com.ua/