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Course code: 601j scolarship application


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Course code: 601J


SCOLARSHIP APPLICATION Universidad Internacional Menéndez Pelayo

Secretaría de Alumnos

C/ Isaac Peral, nº 23. 28040 – MADRID (SPAIN)

Tel.: + 34 91 592 06 31 / + 34 91 592 06 33

Fax: + 34 91 592 06 40 / + 34 91 543 08 97

e-mail: sg@sa.uimp.es


International School of Astrobiology “Josep Comas I Sola”.

Earth Extremophiles and the Habitability of Extraterrestrial Environments

Santander (Spain), 22 – 26 june 2009

PERSONAL INFORMATION




SURNAME: _ NAME: _______________________________ SEX: Male

 Female

NATIONALITY: __________________ Date of Birh: ____________________ Passport number: _____________________


ADDRESS: ___________

(street, square, avenue, etc.)
POSTAL CODE: ____________ TOWN/CITY: _________________________ _____ COUNTRY: ____________________
PHONE: _________________________ FAX: ________________________ __ e-mail: _________ ___________


ACADEMIC BACKGROUND AND PROFESSIONAL EXPERIENCE



UNDERGRADUATE:  GRADUATE: 
NAME OF COLLEGE/UNIVERSITY: _______________________________________________________________ ________
SUBJECT OF YOUR UNIVERSITY STUDIES: ________________________________________________________ ________
POCCUPATION: __________
COMPANY: __________
Please tick one of these options
Registration grant

registration and accommodation grant (travel expenses are not included)
DOCUMENTS REQUIRED




Date: Signature: _____________________________________


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