REGISTRATION FORM or CHANGE OF INSTITUTE - LHCb

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 : …………………………………………….