In doctoral study programme:
Applicant’s name, surname, title:
Postal address:
Department / workplace:
Study programme / branch:
Supervisor / supervisor-specialist:

Start date of a study:
State doctoral exam passed on:
Current study form:    full-time  –  distant  –  part-time

The Czech title of the dissertation thesis:

The English title of the dissertation thesis:

Student signature:
Phone:
E-mail

Programme Board statement:

Required attachments – see page 2   

1.	The dissertation thesis (up to 150 pages) in electronic format pdf, possibly a printed version according to the requirements of study program representatives. The thesis must comply with the conditions set out in Article of the Dean’s Directive for the Defence of Dissertation Theses at FEE.
2.	Professional CV supplemented with an overview of the author’s publications, signed by hand.
3.	The statement of the doctoral student authorizing the immediate unlimited publication of his/her dissertation thesis in electronic form. In case the statement to publication is not provided the theses according to Art. 2.3d) of the Dean’s Directive for Dissertation theses at FEE of this document must be submitted.
4.	An honour statement by the doctoral student that he/she has worked independently, consistently quoting the literature used and explicitly determining his/her share of the submitted thesis.
5.	The abstracts and keywords of the dissertation thesis, in a searchable electronic txt file delivered electronically.
6.	Proving internationalization of the doctoral student according to DSC FEE, Art. 8 Para 3.

Agreement for publishing the dissertation thesis

I, Ing. John Student, resident od Science Street 1353/8, 123 45 Science-fiction, born 01.01.2211, give CTU in Prague, the Faculty of Electrical Engineering (hereinafter FEE) permanent, irrevocable consent to publish my dissertation thesis called:

New Method of High Voltage Mitochondrial Protection.

Publishing can precede the defence of the dissertation and also the review process.

I also clarify that this dissertation does not infringe upon the copy rights of third parties and that I am aware of the fact that i tis re necessary to submit potential patent applications before publishing the dissertation.

Prague, date: ………………………………………………              Signature ……………………………………………..…………………

Honour statement

Name and surname of the doctoral student:

I declare that I have written my dissertation thesis independently and consistently quoted the sources in the submitted work.

Specification of the author’s share:

Prague, date …………………………………………….                        Signature ……………………………………………………………

Proving internationalisation

Name, surname, title: …………………………………………………………………………………………………………………………………. 
Start date of study: …	
The form of study:      full-time / combined / part-time (cross out not applicable)
Study programme / branch: 	
Department / workplace: …….…………………………………………………………………………………………………………………….
Supervisor: 	
Supervisor specialist: 	

Means of meeting the internationalisation requirement:
1)	International internship

Institution name:…...……………………………………………………………………………………………………………………………………
Contact person: ………………….…..……………………………………………………………………………………………………………….…..
Term of stay: …………………………………………………………………………………………………………………………………………….…..
Results: ……………………………………..………………………………………………………………………………………………………..……….
……………………………………………………………….………………………………………………………………………………………………..……..
……………………………………………………………….……………………………………………………………………………………………………….

2)	Participation in an international project with results published abroad or another form2

Title and the investigator of the project3: ……………………………………………………………………………………..………..
……………………………………………………………………………………………………………………………………………………………………….
Results4:..………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………….
Reasons for choosing the option 2): ……………………………………………………………………………………………..….……..
………………………………………………………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………………………………………………………..

Prague, date: …………………………………………………..

Student signature: ……………………………………….. 	Supervisor signature: …………………………………………………..