Lorentz Center - ICT with Industry 2019 from 21 Jan 2019 through 25 Jan 2019
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    ICT with Industry 2019
    from 21 Jan 2019 through 25 Jan 2019

 
Family Name (Last Name): 
First Name:
Gender: 
Date of Birth:  Type yyyy-mm-dd or Press-> (required for internet access)
Institute (affiliation): 
Address: 
Zip Code: 
City: 
Country: 
Telephone:
Email: 
Personal Homepage:  (to be linked to your name in the participants list)
Please check as appropriate 

Almost all Lorentz Center workshops welcome participation of not-invited researchers with an interest in the theme of the workshop, space permitting, while members from the Dutch scientific community are in principle always welcome at the workshops. Please provide below any information concerning your research or background that may be helpful to the organizers in deciding concerning your admission (research field, papers on the subject, collaborations, etc.)

Please state your reasons for wanting to attend the workshop and give a list of recent publications in related areas.
Reasons for attending:  
Publications:  
Contact person in case of emergency:  
Telephone number contact person:  
Current Professional Status:  
Participants are expected to stay for the entire workshop week and will stay in the nearby hotel Van der Valk. Your accommodation will be covered. Participants will share a room with another person. Single rooms are available, upon payment of extra cost and will be charged on own account.
Arrival date: Type yyyy-mm-dd or Press->
Departure date: Type yyyy-mm-dd or Press->
Hotel needed
My special requirements regarding hotel accommodation,
meat/food are (eg wheel chair access, presence of elevator)
Please indicate which business challenge you would like to sign up for in order of preference:
First Choice
Second Choice
If you would like to motivate your case preference, please do so here: (optional) 
What is your affiliation, research group and name of supervisor: (mandatory) 
Please describe in briefly keywords your expertise: (mandatory).  
You can now  this form or  it.

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