Personal details:

Title: Prof    Dr    Other   

Name:

Date of Birth:

Sex: Female    Male

Citizenship:

Personal Address:

Phone: , Fax:

EMail:

Web Page:

Is this your preferred mailing address: Yes

Academic details:

Name and Address of your Institution:

Phone: , Fax:

EMail:
(the initial registration confirmation will be emailed to this address, please make sure you enter a valid address)

Web Page:

Is this your preferred mailing address: Yes

Present position (student, lecturer, other to be specified):

Latest degree (specify date and university):

Degree in preparation (specify university):

Research field:

Do you belong to a research group? Which one?

Name of the person in charge:

Number of persons working in this research group:

Travel Details:

Estimated cost of your travel in economy class: (in EUR)

Financed by:

Amount of the grant: (in EUR)

Flight into Sri Lanka (if known)   (e.g., UL777)
Arrival Date:   Arrival Time:

Flight from Sri Lanka (if known)   
Departure Date:   Departure Time:

Local travel to Matara:

Train    Car    Other    Estimated arrival time:  

Financial Support Details:

Accomodation:

Financed by:

Amount of the grant: (in EUR)

Registration fee:

Financed by:

Amount of the grant: (in EUR)

List institutions you have applied to for financial support (other than CIMPA):

Are you working in a developing country and would like to apply for partial support?

Yes    No

Conference preferences:

Would you like to present a poster / short presentation?

Yes    No

Title:

Dietary requirements:

None    Vegetarian    Vegan    Other    Please specify:  

Will you be accompanied with additional accompanying persons and shall need accomodation for them at your own cost? Yes    No

Further issues:

Do you have personal insurance covering illness, injuries and other risks? Yes    No

NOTE : In any case CIMPA will not cover your health care, hospitalization and repatriation expenses. Health insurance is mandatory and you must provide evidence.

Did you already participate in a CIMPA school? If you did, please list title(s) and year(s) of the School(s):

And last, please do not forget to send us per email, fax or post:

• 1 letter stating your motivations
• 1 curriculum vitae
• 2 different letters of recommendation
• 1 passport photograph