Application for the
June
18-22 2018
MDC, Berlin
Please fill out this page and
submit it by E-mail to Dr.
Suzanne M. Leal.
Please simply paste the form into a body of an e-mail
and fill out the form.
First name & title:
_____________________________________________________
Last name & title:
_____________________________________________________
Title:________________________________________________________________
Highest
Degree(s)______________________________________________________
Company / University
__________________________________________________
Department:
__________________________________________________________
Address:
_____________________________________________________________
____________________________________________________________________
____________________________________________________________________
City
__________________________Country________________________________
Tel. number:
_________________________________________________________
E-mail:
______________________________________________________________
Male/Female__________________________________________________________
Special Interests (e.g.
Bipolar Disease, asthma, method development, etc)
_________
_____________________________________________________________________
_____________________________________________________________________
Are you a
________pre-doctoral
student _________post-doctoral fellow, ______faculty or _________other (please
specify _______________________)
MDC housing:
(___) I wish to use housing
at the MDC campus.
(___) I will make my own
hotel arrangements.
Will
you need a visa to enter Germany to attend the course?
(___)
yes (___) no
If
you will need a visa to attend the course please give the address for the
German consulate where you will be applying for a visa.
We
will provide you with a letter to aid you with your visa application
___________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Note: Due to a
limited number of rooms, we cannot guarantee housing at the MDC. We will
forward information on how to make reservations at MDC and at two nearby hotels
with the acceptance letter.
Applications are accepted on
a "first come, first served" basis. Applications will be
accepted after the due date; if the course is filled, you will be placed on a
waiting list.
Payments
directions: Please send no money now. Applicants accepted for the course will
receive payment instructions.