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Downloads |
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CIMPA Application Form COMPLETE FILES WILL BE CONSIDERED You will need to PRINT this form and mail it to CIMPA to the address below, along with the required additional documents. |
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| Title of the CIMPA school: | ......................................................... | |
| Did you already participate in a CIMPA school? If you did, please list title(s) and year(s) of the School(s): | .................................................................................. .................................................................................. .................................................................................. |
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| Last Name: | .......................................... | |
| Given Name: | .......................................... | |
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Birthdate:
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Citizenship:
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.......................................... | |
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Personal
address:
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.......................................... .......................................... |
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Name
and address
of your institution: |
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.......................................... .......................................... .......................................... |
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Present
position:
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.......................................... | |
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Latest
degree:
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.......................................... | |
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University:
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.......................................... | |
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Date:
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.......................................... | |
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Prepared
degree:
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.......................................... | |
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University:
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.......................................... | |
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Research
field:
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.......................................... | |
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Do
you belong to a
research group? |
Yes No | |
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If
so, which one?
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.......................................... | |
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Name
of person in charge:
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.......................................... | |
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Number
of persons working in this research group:
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.......................................... | |
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Estimated
total cost of your travel in economic class:
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.......................................... | |
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Details
of your financial arrangements (enclose evidences):
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| Travel financed by: | .......................................... | |
| Amount of the financing: | .......................................... | |
| Stay financed by: | .......................................... | |
| Amount of the financing: | .......................................... | |
| Registration
fees financed by: |
.......................................... | |
| Amount of the financing: | .......................................... | |
| List of institutions (excluding CIMPA) you have applied for financial support and from which you are waiting for a reply: | .......................................... .......................................... .......................................... .......................................... |
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| Your more convenient mailing address? | Personal Professional | |
| Telephone : | .......................................... | |
| Fax: | .......................................... | |
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E-mail
:
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.......................................... | |
| The quickest and most reliable way to contact you: | ||
| Ordinary mail | ||
| Fax | ||
| Telex | ||
| Do you have a personal insurance covering ilness, injuries or other risks? | Yes No | |
| NOTE : In any case CIMPA will not cover your care, hospitalization and repatriation expenses. Health insurance is mandatory. | ||
Date and signature: .......................................... |
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To
be returned to: Together
with: |
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