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\centerline{\huge \bf VIth OPORTO MEETING ON }

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\centerline{\huge \bf GEOMETRY, TOPOLOGY AND PHYSICS}

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\centerline{\huge \bf	APPLICATION FORM} 

 
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Please complete and return this form at the latest by 16th May, 1997.

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\noindent (1) electronically to Roger Picken: picken@math.ist.utl.pt,\\
(2) by fax to  + 351-1-8417598, or\\
(3) by mail to the following address:\\


\noindent Professor Roger Picken,\\
Departamento de Matematica,\\
Instituto Superior Tecnico,\\
Avenida Rovisco Pais,\\
1096 Lisboa Codex,\\
PORTUGAL


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\item[] Name:

\item[] Institute Address (full mailing address):

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\item[] E-mail Address: 

\item[] Phone:                   

\item[] Fax: 


   
\item[] If you wish to give a seminar please state the title. (Please 
note that it may
be impossible to arrange a slot for everyone due to the tight schedule.) 
Title: 

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\item[] 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 on your
behalf:  

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\item[] If you require full or partial financial support in order to attend, 
please
explain your situation. (Please note that it is quite likely that no such
support will be available. 

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}

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