European Union

ANNEX 2

APPLICATION FORM

EUSR for the South Caucasus

and the crisis in Georgia

Instructions: Please fill the application electronically and answer each question clearly and completely.

Police liaison officer - based in Georgia - Zugdidi
A – PERSONAL DATA
Family Name	First Name	Passport/ID number
Date of Birth (DD/MM/YYYY)	Place of Birth	Country of Birth	Gender
Present nationality	Do you have multiple nationalities?	Other nationality
Marital Status	Dependents	Blood Type

Mailing Address (or where you may be reached)

Street	Zip/Postal Code
Town/City	County/State/Province	Country
Telephone No.	Fax No.	Email Address

B – EDUCATION AND PROFESSIONAL TRAINING

University Education or Equivalent

Give full details in chronological order starting from the most recent degree/diploma achieved. Include courses and post-graduate studies if applicable.

Name Institution /University place and country	Degrees/Qualifications Obtained (Title of qualification awarded)	Main Course/Field of Study	Attended (mm/yy)
From:	To:

C – EMPLOYMENT RECORD

Starting with your current position, list in reverse chronological order relevant professional positions held. Use a separate block for each position.

Organisation, place and country	Position Held	Category/Rank	Date (mm/yy)
From	To
Description of your duties and responsibilities:

Previous relevant positions (1)

Organisation, place and country	Position Held	Category/Rank	Date (mm/yy)
From	To
Description of your duties and responsibilities:

Previous relevant positions (2)

Organisation, place and country	Position Held	Category/Rank	Date (mm/yy)
From	To
Description of your duties and responsibilities:

Previous relevant positions (3)

Organisation, place and country	Position Held	Category/Rank	Date (mm/yy)
From	To
Description of your duties and responsibilities:

Other previous employment

Organisation, place and country	Position Held	Category/Rank	Date (mm/yy)
From	To

Previous international field mission experience

(Please provide exact details in reverse chronological order.)

Organisation	Place and country	Position Held	Date (mm/yy)
From	To

D – FURTHER SKILLS

Native Language

Level of proficiency
Other languages	Speak	Write	Read	Understand

A = Professional Fluency; B = Working Knowledge; C = Limited Knowledge

E – ADDITIONAL INFORMATION

List your current membership(s) in professional associations/societies and your activities in civic, public or international organisations or affairs

List trades/professions in which you are currently licensed

List any significant publications you have written (Do not attach)

Explain briefly why you wish to join the EUSR Office

By submitting this application form, I certify that the statements made by me in answer to the foregoing questions are true, complete and correct to the best of my knowledge and belief. I understand that any misrepresentation or material omission made on the Application Form will result in the application being void and will result in termination or dismissal from the mission.
Signature	Place	Date