NEUTRINHOUCHES 2001 APPLICATION FORM

Deadline : Sent the form below completed to 
           neutrinhouches@clermont.in2p3.fr 
           BEFORE MARCH, 24 2001

All participants to the Workshop are required to register, preferably as soon
as possible. Applications for attending the Meeting and for financial support
will be reviewed in March. 

GENERAL INFORMATIONS :
Name        :
First Name  :
Institute   :
e-Mail      :
Tel         :
Fax         :
Postal Addr.:

CONTRIBUTION :
Do you intend to give a contribution in the afternoon session(s) ? (Yes/No)*
On which day (1->5)   : 
Provisional Title     :
Preprint if available :
Short Summary         :

PRACTICAL INFORMATIONS :
Date of Arrival (June 17->22)  : June 17 by default
Date of Departure (June 18->23): June 23 by default
Will you be taking the conference bus ? (Yes/No)*
If not, will you be coming by:  (car/train/Geneva bus)*
Do you need an invitation letter? (Yes/No)*

FINANCIAL SUPPORT :
Do you apply for financial support from the organizing committee ? (Yes/No)*
Nationality                     :
Date of birth (if less than 36) :
Other sources of support        :
Estimated amount of other support (in euros) :
Estimated travel costs (in euros)            :


()*: Choose one possility.