Registration Form

General FANTOM Study Week Groningen, 7-11 November 2011

If you wish to participate in the study week in Groningen, please fill out this form and submit it, or send the information requested to the FANTOM secretary otherwise (address see below).

	Name
	Sex	Female Male
	Institute
	Work Address
	Telephone number:
	Email Address
	Topic of PhD Research
	Start Date of PhD Research
	PhD Supervisor(s)
	Do you wish to give a 15 minute oral presentation during the study week?	Yes No
	If yes, the (preliminary) title will be:
	If you are on a diet or if you choose not to eat specific food, please mention this, so that arrangements can be made for you.

For participants from outside KVI - unless indicated otherwise - a hotel room will be booked as follows: arrival date Monday 7 November, departure date Thursday 10 November 2011. Please notify the FANTOM secretary if you will arrive or depart on another date!

Remarks, if any

N.B.: Please make sure that the information requested above reaches the FANTOM Secretary BEFORE 1 OCTOBER 2011.

For further information please contact the FANTOM secretary:
Amarins Petitiaux
KVI
Zernikelaan 25
NL-9747 AA Groningen
The Netherlands
Phone: +31 50 363 7522
Fax: +31 50 363 4003
E-mail: petitiaux@kvi.nl

Registration Form

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FANTOM International Research School