Application form

CIMPA APPLICATION FORM

Title of the CIMPA School:
Quantum symmetries in theoretical physics and mathematics ``Bariloche 2000''

First Name:                                                 Last name:
Birthdate:                                 Sex:                         Citizenship:

Did you already participate in a CIMPA school? If you did, please list title(s) and year(s) of the School(s):

Personal address:

Name and address of your Institution:

Present position:

Latest degree (specify date and university):

Prepared degree (specify university):

Research field:

Do you belong to a research group? Which one?

Name of the person in charge:

Number of persons working in this research group:

Estimeted cost of your travel economic class:

Details of your financial arrangements (enclose evidences):
Travel:
Financed by:                                                         Amount:

Stay:
Financed by:                                                         Amount:

List of institutions (excluding CIMPA) you have applied for financial support and from wich you are waiting for a reply:

Your more convenient mailing address? Personal ( ) Professional ( )

Phone:                                                         Fax:
E-mail:

The quickest and most reliable way to contact you (ordinary mail, fax, telex, e-mail):

Do you have a personal insurance covering illness, injuries or other risks?

NOTE: In any case CIMPA will not cover your care, hospitalization and repatriation expenses. Health insurance is mandatory.

Date and signature:

To be returned to:

Jeanick ALLANIC
CIMPA
Le Dubellay - Bat. B
4, Avenue Joachim
06000 Nice - FRANCE

Together with:

• 1 passport photographs,
• 1 curriculum vitae (indicate all your works and research groups, and international collaborations)

If you are a student and ask financial support from CIMPA, you should also send:

• 1 letter stating your motivations,
• 2 different recommendation letters.