Application Form
COMPLETE FILES WILL BE CONSIDERED
If you are applying from outside Colombia and you intend to apply for
financial aid, you need to send an additional form
to CIMPA |
| Last
Name: |
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| Given
Name: |
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Birthdate:
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Citizenship:
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Personal
address:
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Name
and address
of your institution:
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Present
position:
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Latest
degree:
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University:
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Date:
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Prepared
degree:
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University:
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Research
field:
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Do
you belong to a
research group?
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Yes
No
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If
so, which one?
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Name
of person in charge:
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Number
of persons working in this research group:
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Estimated
total cost of your travel in economic class:
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Details
of your financial arrangements (enclose evidences):
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| Travel
financed by: |
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| Amount
of the financing: |
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| Stay
financed by: |
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| Amount
of the financing: |
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Registration
fees
financed by: |
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| Amount
of the financing: |
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| List
of institutions (excluding CIMPA) you have applied for financial support
and from which you are waiting for a reply: |
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Your more convenient mailing address? |
Personal
Professional
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| Telephone
: |
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| Fax: |
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E-mail
:
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| The
quickest and most reliable way to contact you: |
| Ordinary
mail |
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| Fax |
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| Telex |
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| E-mail |
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Do you have a personal insurance covering ilness, injuries or other risks? |
Yes
No
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| NOTE
: In any case CIMPA will not cover your care, hospitalization and repatriation
expenses. Health insurance is mandatory. |
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