Please note: this form should be faxed or posted, since it must be signed by you and a senior scientist (unless, of course, you are a senior scientist!); please print it out, fill it in and send it by post or fax to:
Les Rencontres de Blois
Professeur Jean Tran Thanh Van
BP 33 – 104 avenue du général Leclerc
F – 91192 Gif-sur-Yvette cédex
Fax: 33 (0)1 69288659
Please send your applications as soon as possible;
deadline for applications: January 25, 2006
However, if for some reason you are unable to fax the document, you may:
1) scan it, and send the pages as attached image files (.jpg) by email to:
Jean.Tran-Thanh-Van@th.u-psud.fr
or
2) just send the CV by email; we can sort out the admin. later.
I wish to apply for a grant to attend the conference:
XVIIIèmes Rencontres de Blois
Planetary Science: challenges and discoveries
Blois, Loire Valley, France May 28th - June 2nd, 2006
| Family name ............................................................................................ |
first name ............................................................................................ |
| Age ............................................................................................ |
Citizenship ............................................................................................ |
| Professional Status ............................................................................................ | |
| Institute/University/Company ............................................................................................ phone: fax: email: |
Address ... ... ... |
Date of first university (or equivalent) graduation ...................................... Discipline
Graduated at
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Brief curriculum vitae since graduation
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Current and projected research activities, including motives for wishing to attend this Euroconference
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Do you or your research group hold a grant from which Euroconference participation could be funded?
Yes or No
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Have you applied for a grant for this conference from any other body?
Yes or No
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If "yes", with what result?
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Please indicate here at most 5 of your most recent or best publications
(Title, authors, journal, year, volume and page numbers)
1)
2)
3)
4)
5)
I declare the above information to be truthful and sincere. I do not expect to be funded for this Euroconference from sources other than those indicated above, and if awarded a grant by the Euroconference organisers, I will not try to obtain funding from more than one other source.
Date: ............................................................Signed:
Please note that Euroconference grants can only cover living expenses in Blois; travel expenses cannot be covered.
Recommendation from a senior scientist (supervisor, department head, etc.)
| Name .......... |
Institute |
| Position ............ |
Relation to applicant |
| Recommendation ..... ..... .... ..... ..... .... |
Date: ...................................................................... Signed