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Mme/Mrs.
Mlle/Ms.
M./Mr.
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Nom/Surname |
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Prénom/First Name |
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Date de naissance/Date of birth |
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Nationalité/Nationality |
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Adresse personnelle/Home address |
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E-mail |
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Fonction actuelle/Current position |
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University/Institute/Lab |
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Adresse/Address |
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Téléphone/Phone |
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Telecopie/Fax |
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If you are a Student or Postdoc check this box
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I request a room in student residence for the following dates (this option is only valid if you register before Nov. 15th): |
January 27th,
January 28th,
January 29th,
January 30th,
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I request funding for my stay |
Yes
No |
I request travel expenses (amount in euros) |
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Please check here if the award of travel expenses is a condition of your participation to the workshop |
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Dates du séjour/Dates of stay |
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Arrivée le/Arrival |
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Départ le/Departure |
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