Please return this form before April 30th, 2003 to:
J. Trân Thanh Vân - Rencontres de Blois
Université de Paris-Sud
LPTHE - Batiment 210
91405 Orsay Cédex - France.
Fax : (33 1) 69 15 82 87
or E-mail: claude.barthelemy@th.u-psud.fr
I wish to apply for grant to attend the Conference : Physical cosmology, Blois, France, June 15-20, 2003 Name : ............................................................... First name : ......................................................... Date of birth : ............ Citizenship : ................................ Professionnal status : ............................................... University/Company : ................................................. Zip : ........... City : ............. Country : ..................... Tel : .......................... Fax : .............................. E-mail : ............................................................. First University (or equivalent) graduation date : ................... Discipline : ......................................................... Institution of graduation : .......................................... Brief curriculum vitae since graduation : ............................ ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... ...................................................................... Current or projected research activities and motives for wishing to attend the conference : ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... ....................................................................... 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 (not more than 5, your best or most recent) Give title of paper, journal, volume and page numbers, authors. 1. ....................................................................... .......................................................................... 2. ....................................................................... .......................................................................... 3. ....................................................................... .......................................................................... 4. ....................................................................... .......................................................................... 5. ....................................................................... .......................................................................... I declare the above truthful and sincere. I do not expect to be funded for conference participation from other sources except as above, and if awarded a grant by the conference organisers, I will not cover any expenses from more than one funding source. Date : ........................ Signed :