application form DOREMI IC CEA course by 5Y5U7F0

VIEWS: 4 PAGES: 3

									   IC/CEA DOREMI training course on Inter-individual variability of radiation-
                 sensitivity: Mechanisms and Biomarkers

Part 1: Application to attend lecture series 10th – 14th December 2012
                         DEADLINE 17th OCTOBER 2012

Surname:
First name:
Work address:

Telephone number:
Fax number:
Email:
Nationality:
Is a visa necessary to enter France: Yes/No*
Please note applicants are responsible for obtaining all necessary visas and travel documents
Date of birth (day/month/year): ……/….../…….

Status*
M2 student/PhD student (1st/2nd/3rd/4th year)/Postdoc/other

If other:
Position held:
Employer:

For M2 students please specify:
Title of M2 project:
University affiliation:
Name of M2 supervisor:
Email of M2 supervisor:

For PhD students please specify:
Title of PhD project:
University affiliation:
Name of PhD supervisor:
Email of PhD supervisor:

For Postdocs please specify:
Title of research project:
Name of supervisor:
Email of supervisor:
Date PhD obtained: (day/month/year)……/……/…….. from …………………University
Name of PhD supervisor:



*please cross-out those that do not apply
Please provide a short description of your own research project and why you would like to
attend the lecture series:




I , ………………………………., if accepted to attend the DOREMI course, will attend all lectures
from Monday 10th December to Friday 14th December 2012.
Signature of applicant:
Date:


I, ………………………………., M2/PhD/postdoc supervisor /employer* of …………………………
will allow him/her the necessary time to attend all lectures and fully participate in the DOREMI
course from Monday 10th December to Friday 14th December 2012.
Signature of supervisor/employer*:
Date:




                 Please return signed forms to studentsdoremi2012@curie.fr
*please cross-out those that do not apply
Part 2: Pre-application to attend laboratory sessions 17th – 21st December 2012
DEADLINE FOR RETURN OF PRE-APPLICATION FORM 10th OCTOBER 2012

Students for the second week of the course will be selected based on their having attended the first
week’s lecture course, their motivation and scientific background and being able to obtain the necessary
security clearance from the CEA so that they can enter the CEA’s Saclay site where the laboratory
sessions will be held. In order to be considered for this second week, please complete and return the
following pre-application questions below together with part 1 of this application BEFORE 10TH OCTOBER
2012. Based on this information, selected students will have to return by 17th OCTOBER 2012 the following
additional documents to initiate the security clearance authorization: your ID picture, a copy of your ID card
or of your passport, and the completed “sphère du nucléaire” document that they you will be sent on return
of this pre-application. Any application that does not respect these time delays cannot be considered. A
copy of your civil liability and, for the people with a nationality from outside the European Union a copy of
your visa and residence permit, will also be required.
Please note this information is not necessary for those that only wish to apply for the lecture series.
Surname:
First name:
Date of birth (day/month/year): ……/….../…….
Nationality:

Please note applicants are responsible for obtaining all necessary visas and travel documents
Please provide a short outline of why you want to attend the laboratory training and what
you hope to learn and how this will help you in your research project.




I , ………………………………., if accepted to attend the DOREMI course , will attend all laboratory
sessions from Monday 17th December to Friday 21st December 2012. I agree that the CEA can
carry out the necessary security checks in order that I can enter the CEA premises.
Signature of applicant:
Date:
I, ………………………………., M2/PhD/postdoc supervisor/employer* of ……………………………
will allow him/her the necessary time to fully participate in the laboratory session of the DOREMI
course from Monday 17th December to Friday 21st December 2012.
Signature of supervisor/employer*:
Date:
         Please return signed sections 1 and 2 to studentsdoremi2012@curie.fr
*please cross-out those that do not apply

								
To top