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Sponsored by the
European Commission 
Dynamical Systems in Physiology and Medicine

FINANCIAL SUPPORT FORM

  You may apply for financial support by filling in the follow form:

Name
Surname
gender F   M
Date of birth
Nationality
Country of residence
Title
Position
Institution
Do you work in an industrial setting? YES    NO
Address
Phone
Fax
E-mail
First University (or equivalent) graduation date:
Discipline:
Institution of graduation:

Do you already hold a Ph.D.?

YES     NO
Ph.D Area:
(Expected) Ph.D graduation year:

Brief curriculum vitae since graduation:

Current or projected research activities and motives for wishing to attend the
3rd ESMTB Summer School, Urbino 2002:

Do you or your research group hold a grant from which participation in the event could be funded?  YES    NO

Have you applied for a grant for this purpose from any other body?   YES    No

If yes, what result?  

 

Scientific publications of applicant (no more than 5, your best or most recent; give authors, title of paper, journal, volume and page numbers, publication year)

1
  
2
  
3
  
4
  
5
  

If including recommendation letters, they must be printed, signed by the supervisor and handed over to the organizers once in Urbino, in order for the support to be granted.

Recommendation Letter 1 : comments on benefit of participation from Supervisor, Department Head, etc.
Name:
Institution:
Position:
Relationship to applicant:
Comments:

Recommendation Letter 2 : comments on benefit of participation from Supervisor,Department Head, etc.
Name:
Institution:
Position:
Relationship to applicant:
Comments: