Workshop2013:registrationform

Registration form

If you have already send this form, please do not send it again!

In order to amend you application or with other queries please email gaiasciencealertsworkshop2013@gmail.com

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Contact details

Title (Mr/Mrs/Dr/Prof):	name=dr|cols=5|style=width:auto|rows=1}}
Name:	name=name}}
Affiliation:	name=affiliation|cols=50|style=width:auto|rows=1}}
Work address:	name=address|rows=3|cols=30|style=width:auto}}
Telephone:	name=tel|value=don't forget your country code|cols=30|style=width:auto|rows=1}}
Email:	name=email|rows=1|cols=20|style=width:auto}}

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Please give a short description of your current research and research interests, as well as a description of how you will contribute to and benefit from the workshop (<400 words) {{#input:type=textarea|name=research|rows=6|cols=100|style=width:auto}}

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My contribution to the Workshop:

name=contribution| Please select talk poster none}}

Title:	name=title|rows=1|cols=100|style=width:auto}}
Brief abstract:	name=abstract|rows=4|cols=100|style=width:auto}}

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Social Dinner

We plan to have a workshop's dinner on Thursday 20th

I would like to participate in the dinner:

name=dinner| Please select yes no}}

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Other

Special dietary requirements (e.g. vegetarian, vegan):

name=diet|value=No special dietary requirements}}

Disabled access:

name=disabled|value=No special disabled requirements}}

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Funding

Should you request any funding support, please email us directly with a justification and an estimate of the travel and accommodation costs. The support is available primarily for students and postdocs.

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Now, make sure everything you entered is ok. If form is processed successfully you will receive a confirmation email.

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{{#input:type=submit|value=Send}}

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