------------------------------------------------------------ SCHOOL ON REFINEMENT Jointly Organised by University of Tunis El Manar University of York UNU-IIST 13-17 November 2006, Tunis, Tunisia ------------------------------------------------------------ APPLICATION FORM ------------------------------------------------------------ ***** Please edit this file and save it as plain text. ***** ------------------------------------------------------------ mark [X] to select a choice, leave [ ] unmarked, oterwise ------------------------------------------------------------ Name: Company/University: Current position: Research Interests (if any): Citizenship: Address: City: State: Country: Post code: E-mail: Phone: Fax: Web (if any): Date of Birth (DD/MM/YYYY): Higher degree: [ ] University graduate [ ] Master [ ] PhD awarded by (university): on (date, DD/MM/YYYY): Previous positions (Industry/Academia): * Years: Institution/Company: Position: [Repeat the three lines above, if necessary] Please mark if applicable: [ ] I have a paper accepted at ICTAC 2006 [ ] I have applied for a scholarship to attend ICTAC 2006 EXAMINATION: [ ] I would like to undertake an examination at the end of the school FINANCIAL SUPPORT: [ ] Financial support required. If financial support required, - From which place do you intend to travel? City: Country: Transportation: [ ] Air [ ] Land [ ] Sea - Estimated costs of a return trip: US$ _________ ENGLISH (self-assessed) Excellent Good Average Poor Reading [ ] [ ] [ ] [ ] Speaking [ ] [ ] [ ] [ ] Writing [ ] [ ] [ ] [ ] Listening [ ] [ ] [ ] [ ] Teaching experience: _______________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Industrial experience: _____________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Programming experience (including OS and Tools): ___________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Research experience: _______________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Reasons for attending this school: _________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Expectations from this school: _____________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Please attach: 1) Scanned copies of the university transcript for the completed undergraduate degree (mandatory only for applicants who do not hold an academic position) 2) List of publications (mandatory only for applicants who hold an academic position)