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					              APPLICATION FOR ASSOCIATE MEMBERSHIP
                                       OF THE
              ABDUS SALAM INTERNATIONAL CENTRE FOR THEORETICAL PHYSICS


 Family Name:                           Other Names:
 Sex: M       F   
 ---------------------------------------------------------------------
 FOR WOMEN ONLY: Maiden Name:
 DO YOU WISH TO AVAIL OF THE AGE BENEFIT: YES       NO   
 Date of Birth:                                                         Please attach
 Present Nationality:                                                  a recent photo
 Nationality at Birth:                                                  signed on the
 Place of Birth (City & Country):                                        reverse.
 Marital Status:                 Number of Children:
Full Name and Address of Permanent Institute:




E-Mail:                   Fax:                       Phone:


Full Name and Address of Present Institute:               Telephone:
(IF DIFFERENT FROM PERMANENT INSTITUTE!)
                                                          Telefax:


                                                          E-Mail:
Address Valid Until:
Home Address:                                             Telephone:


                                                          Telefax:


                                                          E-Mail:
Mailing Address: Permanent:  Present:  Home: 
EDUCATION (Higher Degrees - start with last Institute attended)

Name of Institute           Dates attended      Qualification Obtained
Have you participated in past ICTP activities? YES       NO   
If Yes, which?




Participation in other Seminars, Summer schools, Conferences etc.

Name & Place                                   Year




SCIENTIFIC EMPLOYMENT AND ACADEMIC RESPONSIBILITY

Name of Institute         Period of Service                      Duties




Describe your present employment and duties, stating also any
Position you hold in the scientific administration of your institute.




Give a brief account of your work, its highlights and your
present research problems.




Please give details of any scientific society of
professional organization of which you are or have been a member.

Name of Organization                                Your Function
                               FIELD OF INTEREST

PLEASE NUMBER UP TO FIVE FIELDS STARTING WITH THE
PRIMARY FIELD OF INTEREST.




APPLICABLE MATHEMATICS including:
Mathematical Economy,
Mathematics in Industry
Mathematics of Developments,
Systems Analysis

ATOMIC, MOLECULAR PHYSICS

BIOPHYSICS AND NEUROPHYSICS

CLIMATOLOGY AND METEOROLOGY

CONDENSED MATTER PHYSICS

DIGITAL COMMUNICATIONS AND COMPUTER NETWORKING

FLUID DYNAMICS

GEOPHYSICS

HIGH ENERGY AND ASTROPHYSICS

LASERS

MATHEMATICAL PHYSICS

MATHEMATICS

MEDICAL PHYSICS

MICROELECTRONICS

NON-CONVENTIONAL ENERGY (SOLAR, WIND AND OTHERS)

NUCLEAR PHYSICS

PLASMA PHYSICS

SOIL PHYSICS



SPECIFY YOUR MAIN RESEARCH TOPICS USING A MAXIMUM OF 80 CHARACTERS:
List foreign research institutes visited.
Host Institute     Duration of visit                         Purpose of visit




Give details of any distinctions you have received.




We require recommendation letters from 2 senior scientists who
are familiar with your work (not relatives and preferably from
another institute than your own) in support of your application.
Please provide the name & address of the referees you have
contacted and asked to write to the ICTP directly.

Name                                    Position                 Address
1.


2



LANGUAGES                   What is your mother tongue?

Indicate your proficiency in other languages:

Language                Reading                    Writing             Speaking




Name & Address of person to contact in case of emergency -




Relationship:
Telephone:               Telefax:              E-Mail:
Additional information relevant to your application (optional –
please attach additional pages if necessary). For example,
are you involved in research activities related to specific
needs of your country?


I certify that the statements made by me above are true and
complete. If selected, I undertake to refrain from engaging in
any political or other activities which would reflect unfavourably
on the international status of the Abdus Salam International
Centre for Theoretical Physics. I understand that any breach
of this undertaking may result in the termination of the
arrangements relating to my visits to the Centre.

I agree that my e-mail address(es) and photograph may be made
public on the ICTP WWW page if I receive an award:

       YES      NO   
____________________                ___________________        _________________
Signature of candidate                      Place                     Date

				
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