UNITED NATIONS EDUCATIONAL, SCIENTIFIC AND CULTURAL ORGANIZATION and INTERNATIONAL ATOMIC ENERGY AGENCY the ABDUS SALAM INTERNATIONAL CENTRE FOR THEORETICAL PHYSICS Strada Costiera 11 Telephone: +39-040-2240355 I-34014 Trieste Telefax: +39-040-2240585 Italy E-mail: SMR1492@ictp.trieste.it REQUEST FOR PARTICIPATION Joint DEMOCRITOS - ICTP Winter College on Numerical Methods in Electronic Structure Theory 16 January - 4 February 2003 ________________________________________________________________________________ INSTRUCTIONS Each question must be answered clearly and completely. If more space is required, attach additional pages. This form should be sent by e-mail to SMR1492@ictp.trieste.it or forwarded to: the Abdus Salam International Centre for Theoretical Physics, Winter College on Numerical Methods (c/o Ms. G. De Meo), Strada Costiera 11, I-34014, Trieste, Italy. NOTE: This request will be processed only if the permanent address (and present address, if different) is clearly indicated. The ICTP cannot process any visa request, unless all requested personal data are provided. ============================================================================== P E R S O N A L D A T A ______________________________________________________________________________ SURNAME/FAMILY Name: MAIDEN Name: First name: Middle name(s): Sex: For women only (if applicable) _______________________________________________________________________________ IMPORTANT: PLEASE ALSO COMPLETE THIS SECTION, IF YOUR NAME(S) IN YOUR PASSPORT ARE SPELT DIFFERENTLY FROM THE ABOVE. SURNAME/FAMILY Name: MAIDEN Name: First name: Middle name(s): For women only (if applicable) ______________________________________________________________________________ Place of birth (City and Country): Present nationality: Date of birth: Day - Month - Year ______________________________________________________________________________ Full name/address of permanent Institution: Institute: Tel. No. Telefax Your Office: Tel. No. Telefax E-mail: * ______________________________________________________________________________ Full name/address of present Institution : Institute: Tel. No. (if different from permanent) Telefax Your Office: Tel. No. Telefax: E-mail: * until: Date .................. _____________________________________________________________________________ Home address: Tel. 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As a consequence, when the subject of the present activity is far from your previous applications, an explanation (not more than 200 words) of your change of interest should be included. ____________________________________________________________________________ _____________________________________________________________________________ Kindly supply a keyword description of your current scientific activities, as follows (strictly within indicated lengths) : 1) Area of research: (e.g. SEMICONDUCTOR PHYSICS) ______________________________________________________ (no more than 15 characters) 2) Specific topic of interest: (e.g. BAND STRUCTURE THEORY) _____________________________________________________________ (no more than 30 characters) List your scientific publications including books and articles (authors, title, Journal) in the last five years: _______________________________________________________________________________ Kindly state any positions you hold in the scientific administration of your Institution or any of the national scientific Institutions. _______________________________________________________________________________ Indicate below your proficiency in the English language Reading: Good Average Poor Writing: Good Average Poor Speaking: Good Average Poor ................................................ Signature I certify that the statements made by me above are true and complete. If accepted, I undertake to refrain from engaging in any political or other activities which would reflect unfavourably on the international status of the ICTP. I understand that any breach of this undertaking may result in the termination of the arrangements relating to my visit at the Centre. ________________________________ _________________________ Signature of applicant Date