APPLICATION FORM

(deadline: June 15, 2005)

ATTENTION! YOU MUST COMPLETE ALL FIELDS OF THE FORM! Once you press the "submit" button, the completed form will be forwarded electronically to the Summer School organizers. The form should also appear on your browser page, you should print it, sign it, and send it to the Organizing Committee (mail or fax: +39-041-2348620). If the completed form does NOT appear you may have omitted a field, or there might be server problems.You may experience difficulty viewing and printing the part of the submitted form, it is however usually received correctly in the electronic form. If you do not receive confirmation by e-mail within a few days, or if you do not view the completed form after it is submitted, contact dr. Giorgia Trussardi (ssgc@unive.it) or or dr. Alvise Perosa (alvise@unive.it).
Name: Firstname: Sex: Male Female Date of birth (dd/mm/yyyy): Place of birth: Nationality: Present occupation: University/Company: Number of years in present position: Business Address: Postcode: City: Tel: Fax: Country: Email: Private Address: University of graduation: Graduation date: Discipline: Grade: Please indicate your level of knowledge of the English language: native good fair poor Current or projected research activities and motives for wishing to attend our SUMMER SCHOOL (text only, no figures) : I declare the above truthful I do not expect to be funded for participation in the event from other sources except as above, and that if awarded a grant by the organisers of the event, I will not cover any expenses from more than one funding source. The hard copy of this form, duly signed, must reach the Organizing Commitee by June 15, 2005. Signed: Date: Comments on benefit of partecipation from Supervisor, Department Head, etc. Name: Institution: Position: Relation with applicant: Comments (text only, no figures): Signed: Date: