Last name:

First name:

Affiliation:

Address:

Street:
City:	Postal Code:
Country:

Email: (name@host.domain)

Personal Web Page: (e.g. host.domain/~username)

 

If you are a graduate student or recent PhD please indicate your main research interests and the name of someone willing to send a recommendation letter on your behalf if needed:

Fax:

Do you wish to give a talk (please note that it may be impossible to arrange a slot for everyone due to the tight schedule)? No Yes

IF YES, PLEASE SEND US THE TITLE and a SHORT ABSTRACT (preferably with a list of references):

Do you wish to apply for financial support to help cover mainly local expenses? No Yes

If yes, please describe your circumstances and need for financial support.