ICTP - The Abdus Salam International Centre for Theoretical Physics, Trieste, Italy smr1320/Application UNITED NATIONS EDUCATIONAL SCIENTIFIC AND CULTURAL ORGANIZATION and INTERNATIONAL ATOMIC ENERGY AGENCY the ABDUS SALAM INTERNATIONAL CENTRE FOR THEORETICAL PHYSICS Strada Costiera 11 I-34014 Trieste, Italy Telephone: +39-040-2240346 Telex: 460392 ICTP I Telefax: +39-040-2240585 E-mail: smr1320@ictp.trieste.it REQUEST FOR PARTICIPATION SUMMER SCHOOL on LOW-DIMENSIONAL QUANTUM SYSTEMS: Theory and Experiment 16 - 27 JULY 2001 ________________________________________________________________________________ INSTRUCTIONS Each question must be answered clearly and completely. Type or print in ink. If more space is required, attach additional pages. This form should be forwarded to: the Abdus Salam International Centre for Theoretical Physics, Summer School on Low-Dimensional Quantum Systems, Theory and Experiment, (c/o Ms. D. M. Sauleek), Strada Costiera 11, I-34014, Trieste, Italy, to arrive no later than 31 MARCH 2001. If sending an application by e-mail, please save and send file attachments in RTF format. A recent photograph of the candidate should be attached here, signed legibly on the reverse. NOTE: This request will be processed only if the permanent address (and present address, if different) is clearly indicated. The ICTP cannot process any visa request, unless all requested personal data are provided. ================================================================================ P E R S O N A L D A T A ________________________________________________________________________________ SURNAME/FAMILY Name: MAIDEN Name: For women only (if applicable) First name: Middle name(s): Sex: ________________________________________________________________________________ IMPORTANT: PLEASE ALSO COMPLETE THIS SECTION, IF YOUR NAME(S) IN YOUR ICTP: smr1320/Application 1 PASSPORT ARE SPELT DIFFERENTLY FROM THE ABOVE. SURNAME/FAMILY Name: MAIDEN Name: For women only (if applicable) First name: Middle name(s): ________________________________________________________________________________ Place of birth (City and Country): Present nationality: Date of birth: Year - Month - Day ________________________________________________________________________________ Full address of permanent Institution: Institute: Tel. No. Telex/Cable Telefax Your Office: Tel. No. Telefax E-mail: * ________________________________________________________________________________ Full address of present Institution (if different from permanent): Institute: Tel. No. Telex/Cable Telefax Your Office: Tel.No. Telefax: until: Date ............. E-mail: * ________________________________________________________________________________ Home address: Tel. No. ________________________________________________________________________________ Mailing address - please indicate whether: Permanent Present Home ________________________________________________________________________________ Name and address of person to notify in case of emergency - Relationship: Tel. No. _______________________________________________________________________________ * I agree that my e-mail address(es) may be made public on the ICTP WWW page: YES ...... NO ...... ________________________________________________________________________________ EDUCATION (higher degrees) University or equivalent Years attended Degrees ICTP: smr1320/Application 2 Name and place From to ________________________________________________________________________________ Seminars, summer schools, conferences or research Name and place Year ________________________________________________________________________________ SCIENTIFIC EMPLOYMENT AND ACADEMIC RESPONSIBILITY Research Institution or University Name and place Period of duty From To Academic responsibilities Present employment and duties, and foreseen employment upon return to home country after the activity: ________________________________________________________________________________ Have you participated in past ICTP activities? If yes, which? Yes ...... No ...... Are you applying to any other 2001 ICTP activities? If yes, which? Yes ...... No ...... Mention briefly your previous research experience, and explain your reasons for wishing to participate in this activity: NB: Our Scientific Information System keeps track of all applications made by the candidate to earlier ICTP activities. As a consequence, when the subject of the present activity is far from your previous applications, an explanation (not more than 200 words) of your change of interest should be included. ________________________________________________________________________________ PRESENT FIELD OF INTEREST (please indicate on the list below your TWO primary fields of interest, in order of priority). 10. PHYSICS OF CONDENSED MATTER 11. Solid State Physics 12. Atomic and Molecular Physics 13. Materials Science 14. Surfaces and Interfaces 15. Statistical Physics 16. Computational Physics in Condensed Matter 20. PHYSICS OF HIGH AND INTERMEDIATE ENERGIES ICTP: smr1320/Application 3 21. High Energy and Particle Physics 22. Relativity, Cosmology and Astrophysics 23. Plasma Physics 24. Nuclear Physics 30. MATHEMATICS 31. Applicable Mathematics, including: Mathematical Ecology Systems Analysis Mathematical Economy Mathematics in Industry 33. Algebra 34. Geometry 35. Topology 36. Differential Equations 37. Analysis 38. Mathematical Physics 40. PHYSICS AND ENERGY 41. Physics of Nuclear Reactors 42. Physics of Controlled Fusion 43. Non-Conventional Energy (Solar, Wind others) 44. Nuclear Energy related techologies 50. PHYSICS AND ENVIRONMENT 51. Solid Earth Geophysics 52. Soil Physics 53. Climatology and Meteorology 54. Physics of the Oceans 55. Physics of Desertification 56. Physics of the Atmosphere, Troposphere, Magnetosphere, Aeronomy 57. Environmental Monitoring and Remote Sensing 60. PHYSICS TEACHING 61. English 62. French 63. Spanish 64. Arabic 80. MISCELLANEOUS 81. Others 82. Digital Communications Computer Networking 90. PHYSICS OF THE LIVING STATE 91. Neurophysics 92. Biophysics 93. Medical Physics A0. APPLIED PHYSICS A1. Physics in Industry A2. Microelectronics A3. Fibre Optics for Communications A4. Instrumentation A5. Synchrotron Radiation A6. Non-destructive Evaluation A7. Lasers AA. Applied Superconductivity B1. SPACE PHYSICS ________________________________________________________________________________ ICTP: smr1320/Application 4 Kindly supply a keyword description of your current scientific activities, as follows (strictly within indicated lengths) : 1) Area of research: (e.g. COND.MATT.PHYS., STRONGLY CORR.SYST.) ______________________________________________________ (no more than 15 characters) 2) Specific topic of interest: (e.g. LOW DIM. PHYS.) ______________________________________________________________________ (no more than 30 characters) _______________________________________________________________________________ List your scientific publications including books and articles (authors, title, Journal) in the period 1995-2000: ________________________________________________________________________________ Kindly state any positions you hold in the scientific administration of your Institution or any of the national scientific Institutions. It would be of assistance to the Selection Committee if this request for participation were accompanied by a letter of recommendation, especially for junior physicists. ________________________________________________________________________________ Indicate below your proficiency in the English language Reading: Good Average Poor Writing: Good Average Poor Speaking: Good Average Poor ________________________________________________________________________________ APPLICABLE ONLY FOR CANDIDATES FROM DEVELOPING COUNTRIES (Important: Owing to limited funds, support for travel will be granted only in exceptional cases. Therefore, every effort should be made by applicants to secure support for their fare (or at least a partial contribution) from their home country). Request for Financial Assistance: (Please tick ONE box only) Full Travel + Subsistence ...... Half Travel + Subsistence ...... Subsistence only ...... No financial support requested ...... I certify that if granted funds for my travel, I shall attend the whole activity ................................................ ICTP: smr1320/Application 5 Signature ________________________________________________________________________________ I certify that the statements made by me above are true and complete. If accepted, I undertake to refrain from engaging in any political or other activities which would reflect unfavourably on the international status of the ICTP. I understand that any breach of this undertaking may result in the termination of the arrangements relating to my visit at the Centre. ________________________________ _________________________ Signature of applicant Date BACK to ICTP smr1320 ICTP: smr1320/Application 6