REGISTRATION FORM or CHANGE OF INSTITUTE for USERS (ALL FIELDS MUST BE FILLED IN) Opening hrs: Monday to Friday : 08h30 – 12h30 Monday to Friday: 14h00 – 16h00 Closed Wednesday mornings Surname (Family name) _______________________________________ Local address whilst at CERN ______________________________ First names ________________________________________________ (as indicated in passport) ___________________________________________________________ Sex: Telephone _____________________________________________ M F ___________________________________________________________ Date of Birth: Day ________ Month ________ Year ________________ Private address in the home country _____________________________ Town of birth ____________________ Country ____________________ _____________________________________________________ Nationality(ies) ________________________________________ _____________________________________________________ Telephone _____________________________________________ Passport No. ___________________________ Marital status: Ordinary Single Married If spouse in the local area and does not work Spouse Children Widowed Surname Spouse Passport No. ______________________ Service Valid until: Day _________ Month _________ Year ________________ First name Ordinary Divorced Sex (M/F) Separated Date of Birth (Day Month Year) Nationality(ies) Service Valid until: Day _________ Month _________ Year ________________ Your Institute or University* (name and full address) ___________________________________________________________ ___________________________________________________________ Telephone __________________________________________________ Since when : Day ________ Month ________Year _________________ Your present position _________________________________________ * Proof of employment/enrolment with your institute/university showing start and end dates, is required in English or French Financial support (including all sources of income) during your stay : Monthly over 2800 CHF? If not, other financial resources __________________________________ Yes No Nature of your work while at CERN : Yes No Scientific Eng. Tech . Admin. Do you have a PhD ? Presence at CERN ______________ % from ___________________________________ to __________________________________ Experiment/Project : Primary ___________________ Other ____________________ Org. Unit+ ___________________________________ Internal address: Building _________ Floor _________ Office __________ Tel ____________ Tel ___________ Mobile __________________ E-mail address at which you can be contacted : ________________________________________________________________________________________________________________________ If this changes, please update it, for details: http://cern.ch/ph-dep-UsersOffice/UsersContractsInfo/email.pdf Insurance Who covers you whilst at CERN for : Medical expenses due to illness and private accidents (1) ? ________________________________________________________________________ Medical expenses due to professional accidents (1) ? __________________________________________________________________________ Economic consequences of disability arising from an accident (2) ? __________________________________________________________________ Economic consequences of disability due to illness (2,3) ? __________________________________________________________________________ (1) (2) (3) Proof of Insurance is required Not covered by CHIS (UNIQA) Not covered by ACCIDENTA We certify that, to our knowledge, the above information is correct and complete Date: ______/_______/__________ Your Signature _____________________________________________________________________________ Team Leader / Group Leader+ _____________________________________ Signature ________________________________________ or Deputy _______________________________________________________ Signature ________________________________________ + CERN Group Leader for user not participating in experiment or official project Budget code ________ (if blank, you will be UNABLE to use phone, stores ….) To be completed by CERN Category: USER / UPAS+ ______ % CL Long Term Short Term Duration of contract From ________________ To _________________ Department – Group – Section _________________________________ Comments: ________________________________________________ Prof. Code ____________ Identification No. _____________________ Home Institute Code _____________ Remarks __________________________________________________ Processed Date ________________ Signature ____________________ Verified Date ________________ Signature ____________________ PH/UO/P.P. - 11.08.10 CERN - European Organization for Nuclear Research CERN – Organisation Européenne pour la Recherche Nucléaire Name and Identification number (See overleaf) CERN CH – 1211 GENÈVE 23 CONTRACT Personal – Confidential On behalf of the Director General of the European Organization for Nuclear Research, I am pleased to offer you a contract on the following conditions: Department BE / DG / EN / FP / GS / HR / IT / PH / TE Status User Duration of contract See overleaf Duty station Geneva, Switzerland Working time See overleaf (percentage) It is our understanding that your financial support would be covered from sources other than CERN and that the Organization would accept no financial liability by this contract. In particular, CERN makes no provision for the reimbursement of medical expenses due to illness or accident, whether related to work or not. Such insurance can, however, be obtained by joining the CERN Health Insurance Scheme (CHIS), managed by UNIQA, at your own expense. This does not cover disability or death, since CERN assumes that these risks are covered by your home institute. Therefore, CERN will not assume any responsibility related to these risks. Long term contract: You should contact the Users’ Office at least one week before expiration of the validity of the identity documents issued by CERN regarding contract extension or termination formalities. You will receive a warning, a few weeks before your current contract expires, by e-mail to your address as registered at CERN. Please ensure that it is registered correctly, as described on the Users’ Office web site. You must visit the Users’ Office as soon as possible, bringing with you your access card and/or your attestation, in order to ensure that the validity of the identity documents is extended in time, otherwise all privileges (access, residence, car plates) will be withdrawn automatically. All identity documents issued by CERN must be returned at the end of your final contract with CERN. Short term contract (a single stay of maximum 3 months): The contract is automatically terminated when expired, an extension is not possible. Your CERN access card, car sticker, keys etc. must be returned. This contract is subject to the provisions of the Staff Rules and Regulations and to all other relevant instructions. A copy of the Staff Rules and Regulations is available on request from the Personnel Records Office in the Human Resources Division. The above conditions are based on the information you have supplied to CERN. The Users’ Office must be notified immediately of any change in your personal, professional or financial circumstances affecting these conditions. I accept this contract and the conditions mentioned above. Date : …………………………… Signature : ……………………………………………… For the Users’ Office Date :………………………… Signature : …………………………………………….
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