Application form for a European grant

XXXXth RENCONTRES DE MORIOND
QCD AND HIGH ENERGY HADRONIC INTERACTIONS
Place : La Thuile, Aosta valley, Italy
March 12th -March 19th, 2005

Application Form



Mr  Ms  Name .............................. 

First name : ..............................

Age : ........ Citizenship :...............

Professionnal status :

University/Company :.........................
Zip : ........... City : .............. Country :.........................

Tel :.....................................................................

Fax :.....................................................................

E-mail :..................................................................

Date of diploma giving access to doctoral studies (M.S., DEA, ...) :......................

Discipline : .....................................

Institution of graduation : ...................................

Brief curriculum vitae since graduation 

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.................................................................

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Current or projected research activities and motives for wishing to

attend the conference :

.................................................................

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Do you or your research group hold a grant from which

conference participation could be funded?

Yes / No

Have you applied for a grant for this purpose from any

other body? Yes / No

If yes, what result : .........................................

Scientific publications of applicant (no more than 5, your

best or most recent)

Give title of paper, journal, volume and page numbers, authors.

1...............................................................

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2. ..............................................................

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3. ..............................................................

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4. ..............................................................

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5................................................................

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I declare the above truthful and sincere. I do not expect to

be funded for conference participation from other source

except as above, and that if awarded a grant by the

conference organisers, I will not cover any expenses

from more than one funding source.

Date : ...................    Signed :