INSTITUTE FOR MATHEMATICAL SCIENCES

National University of Singapore

3 Prince Geroge’s Park

Singapore 118402

Republic of Singapore

Telephone: (65) 6874 1897 / Fax: (65) 6873 8292 / E-mail:

APPLICATION FORM FOR PROGRAM PARTICIPATION

POST-GENOME KNOWLEDGE DISCOVERY (JANUARY – JUNE 2002)

Deadline for Application: At least 3 months before commencement of membership

Section 1 : Personal Details

Surname:
Given Name:
Title:
Designation:
Department:
Institution:
Institution Address:
Mailing Address:
(if different from above)
E-mail Address: / Telephone:
Date of Birth: / Fax:
Gender: / Nationality:
Proposed Arrival Date:
Proposed Departure Date:


Section 2 : Accommodation

Please select one of the following options:

[ ] Arrange a lodging for me and _____ accompanying family member(s) at:

1) First Choice:

2) Second Choice:

3) Third Choice:

for the period from ______to ______.

[ ] Help me to arrange for private or university apartment

Briefly describe your requirement:

[ ] I will arrange my own accommodation.

If your family member(s) is to accompany you, please provide the following for each member:

Name / Relationship / City & Country of Birth

Section 3 : Financial Position

Please indicate the type of support you are requesting from IMS (if applicable):

[ ] Travel cost

[ ] Living Expenses

[ ] Both

If you are applying for any type of support from IMS, have you applied or been granted financial support from other sources for your visit: Yes / No .

Section 4 : Letters of Recommendation

(Applicable to those applying for financial support)

If you wish to apply for financial support from IMS, please provide 3 letters of recommendation to be sent by the letter writers directly to the following address:

The Director

Institute for Mathematical Sciences

National University of Singapore

3 Prince George’s Park

Singapore 118402

Republic of Singapore

The following individuals will submit letters of reference for my applications:

1 ______

2 ______

3 ______

Section 5: Curriculum Vitae & List of Publications

Please send in your vitae and list of publications by fax, e-mail or hardcopy.