| Surname: |
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| Name(s): |
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| Sex: |
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| Date of birth (DD/MM/YYYY): |
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| Country of residence: |
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| Citizenship: |
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| Your home institution (full name): |
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| Your position: |
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| Your degree*: |
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| * Please, after submitting this form attach your certificate of degree, if you have an academic degree (PhD, master, etc.) |
| Academic status: |
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| Your research interests and current work (3-5 sentences): |
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| Would you like to present a poster? |
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| Poster title: |
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| Address for communication: | |
| Phone (office): |
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| FAX: |
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| E-mail: |
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| Preliminary arrival date: |
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| Preliminary departure date: |
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| I will be accompanied by: |
Name(s):
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Comments:
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