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Course on "Security: From Basic Concepts and Techniques to
               Formal Models and Methods"

                  Jointly Organised by
      UNU/IIST and "Alexandru Ioan Cuza" University

             4-8 April 2006, Iasi, Romania

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                     APPLICATION FORM
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***** Please edit this file and save it as plain text. *****
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  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]

  Financial support:
    [ ] Financial support required.
    If financial support required, from which place do you
    intend to travel?
       City:
       Country:
       Transportation: [ ] Air     [ ] Land     [ ] Sea


ENGLISH (self-assessed)    Excellent  Good   Average   Poor 
                 Reading      [ ]      [ ]     [ ]      [ ]
                Speaking      [ ]      [ ]     [ ]      [ ]
                 Writing      [ ]      [ ]     [ ]      [ ]
               Listening      [ ]      [ ]     [ ]      [ ]

Teaching experience: _______________________________________
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Industrial experience: _____________________________________
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Programming experience (including OS and Tools): ___________
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Research experience: _______________________________________
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Reasons for attending this course: _________________________
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Expectations from this course: _____________________________
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Please attach:
  1) Scanned copies of the university transcript for the
     completed undergraduate degree.
  2) List of publications (if any)