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 10, 2009

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:

hady.schenten@orange.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:

XXIst Rencontres de Blois

Windows on the Universe

Blois, Loire Valley, France June 21st - June 26th, 2009

Family name

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first name

............................................................................................

Age

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Citizenship

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Professional Status

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Institute/University/Company

............................................................................................

phone:

fax:

email:

Address

...

...

...

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

Graduated at

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Brief curriculum vitae since graduation

...........

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...........

............

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

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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.

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

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

Name

..........

Institute
Position

............

Relation to applicant
Recommendation

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.....

....

.....

.....

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

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