Please note: this form should be faxed or posted, since it must be signed by you and a senior scientist (unless, of course, you are a senior scientist!); please print it out, fill it in and send it by post or fax to:

Les Rencontres de Blois

Professeur Jean Tran Thanh Van

BP 33 – 104 avenue du général Leclerc

F – 91192 Gif-sur-Yvette cédex

Fax: 33 (0)1 69288659

Please send your applications as soon as possible;

deadline for applications: January 31, 2007

However, if for some reason you are unable to fax the document, you may:

1) scan it, and send the pages as attached image files (.jpg) by email to:

Jean.Tran-Thanh-Van@th.u-psud.fr

or

2) just send the CV by email; we can sort out the admin. later.

I wish to apply for a grant to attend the conference:

XIXèmes Rencontres de Blois

Matter and Energy in the Universe

Blois, Loire Valley, France May 20th - May 26th, 2007


Family name

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first name

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Age

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Citizenship

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Professional Status

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Institute/University/Company

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phone:

fax:

email:

Address

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Date of first university (or equivalent) graduation ...................................... Discipline

Graduated at

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Brief curriculum vitae since graduation

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Current and projected research activities, including motives for wishing to attend this Euroconference

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Do you or your research group hold a grant from which Euroconference participation could be funded?

Yes or No

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Have you applied for a grant for this conference from any other body?

Yes or No

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If "yes", with what result?

....


Please indicate here at most 5 of your most recent or best publications

(Title, authors, journal, year, volume and page numbers)

1)

2)

3)

4)

5)

I declare the above information to be truthful and sincere. I do not expect to be funded for this Euroconference from sources other than those indicated above, and if awarded a grant by the Euroconference organisers, I will not try to obtain funding from more than one other source.

Date: ............................................................Signed:

Please note that Euroconference grants can only cover living expenses in Blois; travel expenses cannot be covered.


Recommendation from a senior scientist (supervisor, department head, etc.)

Name

..........

Institute
Position

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Relation to applicant
Recommendation

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Date: ...................................................................... Signed