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:

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