application form - Euroleague for Life Sciences

APPLICATION FORM
Euroleague for Life Sciences - Summer School 2017
“Analysis and utilization of genomic diversity for plant breeding”
6 - 12 August 2017
University of Hohenheim, Stuttgart, Germany
Please complete this form on your computer, sign it and send a scanned version of the signed form to:
gabriele.klumpp@uni-hohenheim.de
Dr. Gabriele Klumpp
Euroleague for Life Sciences (900)
University of Hohenheim, Fruwirthstr. 12, D-70599 Stuttgart, Germany
Application deadline: 31st March 2017 or until places are filled
Personal data
Family name:
First name(s):
Male:
Place and date of birth (day / month / year)
Current address
Street and No.:
Telephone No.:
E-mail:
Postal code and city:
Country:
Academic profile
Degree presently pursued / Major field(s) of study:
University:
Month and year of enrolment:
Planned date of completion
Language proficiency in English:
Listening/speaking:
O basic
O moderate
O good
Writing:
O moderate
O good
O basic
Female:
2
Motivation for participation in the intensive summer university:
Relevant prior studies/ academic background:
List and describe especially those courses you already passed in the field of plant genetics, plant breeding
and/or statistics.
Describe why you consider this course important for your further study and career.
Describe your thesis title and topic and name your supervisor (if applicable)
Signature of applicant
I wish to apply for the ELLS Summer School “Analysis and utilization of genomic diversity for plant breeding”,
6 - 12 August 2017. I hereby confirm that the above information is correct.
I have been informed that I have to ensure adequate health insurance during the duration of the programme .
Date:
Signature:
3
For students from abroad
Alternative/Parents address (August 2017)
Street and No.:
Postal code and city:
Country:
Telephone No.:
Fax No.:
E-mail:
Contact person in case of emergency
Name:
Relationship:
Street and No.:
Postal code and city:
Country:
Telephone No. (Private/ Work)
Fax No.:
E-mail: