Application form for a CIMPA research school

All the fields followed by a "*" must be filled in.

Title of the research school:*

Have you already participated or applied for a CIMPA research school?*

If so, please list title(s) and year(s) of the research school(s):

Name:*
Given name:
Birthdate (DD/MM/YYYY):*
Sex:*	F M
Citizenship:*

Personal address:

Personal tel.:

Name and address of your Institution:

Preferred mailing address?*

Tel. in your institution: Fax: Email :

Quickest and most reliable way to contact you:*

Present position (student, lecturer, other to be specified):*

Latest degree (specify date and university): Title of the diploma:*

Date of the diploma:*

University of the diploma:*

Degree in preparation Title of the diploma:

University of the diploma:

Research

Research field:

Do you belong to a research group?*

Which one?

Name of the person in charge:

Email of the person in charge:

Number of persons working in this research group:

Financing

Estimated cost of your travel in economy class:* *

CIMPA does not have a many financial resources and you are advised to arrange finance for your application with other organizations. It will be easier for CIMPA to help you if you have already have a part of the necessary fundings.

List institutions (other than CIMPA) which you have applied to for financial support (send evidence to CIMPA); tick the box if you have already received support:

	Financed by	Tick if you already got it	Amount	Currency
Travel
Stay
Registration fee

Financial support you ask CIMPA for :

	Amount	Currency
Travel (0 if you ask for nothing)	*
Registration fee (305 Euro)**:

** Most often CIMPA takes in charge the registration fee of the candidates coming from developing countries.

Financing of the stay:*

If you ask CIMPA to partially finance your stay, list the amount you already have for the financing of your stay:

Personal insurance

Do you have personal insurance covering illness, injuries and other risks?* No Yes

In any case CIMPA will not cover your health care, hospitalization and repatriation expenses. Health insurance is mandatory.

Each year CIMPA will send you its yearly programme; if you do not wish to receive it, please tick here

Motivation letter. Explain the motivations for your application:*

Curiculum vitae with all your works, research groups and international collaboration:*

Documents to send to CIMPA

This application form is not sufficient for applying to a CIMPA school. You must send the following documents to CIMPA as soon as possible:

2 different letters of recommendation;
1 copy of the page of your passport with your name, address and photograph;
If necessary, evidence for the financial support you have applied to from other institutions.

These documents, necessary for completing your application, can be sent by email, fax or by ordinary mail.

CIMPA Fax: (33) 4 92 07 05 02

CIMPA address CIMPA
"Le Du Bellay", Bâtiment B
4 avenue Joachim
06100 Nice
FRANCE

Antispam code, type the 3 black characters *

For any technical problem, please send a message to the CIMPA technical staff