APPLICATION FORM

"Workshop on Symplectic Geometry, Contact Geometry and Interactions"

  January 28th-30th, 2010


A list of Hotels near the Institut Henri Poincar is available here

IMPORTANT: All the fields have to be filled. No validation if any field is left blank.

Before confirming your registration, please check that the information you provided is correct.


Mme/Mrs. Mlle/Ms. M./Mr.

Nom/Surname

Prnom/First Name

Date de naissance/Date of birth

Nationalit/Nationality

Adresse personnelle/Home address

E-mail

Fonction actuelle/Current position

University/Institute/Lab

Adresse/Address

Tlphone/Phone

Telecopie/Fax

If you are a Student or Postdoc check this box

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,

I request funding for my stay

Yes No

I request travel expenses (amount in euros)

 

Please check here if the award of travel expenses is a condition of your participation to the workshop

Dates du sjour/Dates of stay

 

Arrive le/Arrival

Dpart le/Departure

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