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					   Second Latin American training course on biosafety for
      human health and the environment in relation to
      potential release of genetically modified vectors

                             APPLICATION FORM

Title                  First name    Last name                 Middle initial(s)


Date of birth          Nationality   Sex (please tick below)
                                     Male         Female
Job title/current position


Affiliation



Mailing address




Telephone                     Fax             Email


Academic degrees




Current post held
Summary of current research interests




How would you describe your own knowledge of biosafety?
Beginner                        Intermediate                             Advanced
Describe your home institution




Describe your plan for applying biosafety after the training, and the benefits of your participation in
the course to you and your home institution/country
List tropical diseases research projects supported by TDR and other international organizations in your
institution. State your level of participation




List biosafety/biosecurity workshops/meetings attended (including those sponsored by TDR)




Names and addresses of your supervisor(s)/senior colleague(s) that you have asked to send letters of
supports towards your participation in this course




Recent publications: List only the five most important publications over the last five years (paper in
press or submitted for publication are also acceptable). Please, give full bibliographic references
(author(s), title, journal, volume, page numbers, year).




Approximate cost of round trip air travel to Medellín, Colombia from your home institution (e-tickets
will be issued as economy class or the lowest airfare available)

				
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