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FACING NATURAL HAZARDS 14.09.-23.09.2015
APPLICATION FORM
Academic Title:
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Last Name:
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First Name:
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Middle Initial:
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Gender/Date of Birth:
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Passport No.
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E-Mail:
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Phone:
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Country of Origin:
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Postal Address:
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_____________________________________________
______________________________________________________________________
street, city, state/province, postal code, country
Organization:
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Department:
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Home page or URL:
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Current profession/status: ____________________________________________
Highest Degree earned:
____________________________________________
Year and Institution:
____________________________________________
Recommended by:
(Name and e-mail address)
Reference 1:
____________________________________________
Reference 2:
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FACING NATURAL HAZARDS 14.09.-23.09.2015
Have you participated in any summer school programmes, if yes, which programme?
_________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
How did you learn about the Potsdam Summer School 2015?
________________________________________________________________________________________
________________________________________________________________________________________
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Would you like to make any comments or suggestions from your side?
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I herewith confirm that I will cover for my health insurance during the Summer School
2015 in Potsdam.
I have read and understood that I will have to pay a tuition fee of € 250 to attend the
Potsdam Summer School 2015. This only applies, if I will be chosen as one of the 35
candidates.
The tuition fee can be waived for participants of developing countries. You can
check on our website if this is applicable to you.
Yes, applicable to me, because: _________________________________________________
Signature/Date:
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