APPLICATION FORM

"Workshop on Symplectic Geometry, Contact Geometry and Interactions"

A list of Hotels near the Institut Henri Poincaré 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
Prénom/First Name
Date de naissance/Date of birth
Nationalité/Nationality
Adresse personnelle/Home address
E-mail
Fonction actuelle/Current position
University/Institute/Lab
Adresse/Address
Téléphone/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 séjour/Dates of stay
Arrivée le/Arrival
Départ le/Departure