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Form A (text version)

Form to request an Associate visit

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ICTP Associateship Scheme

Associate Member's Request to Visit the Abdus Salam  ICTP

FORM A

SURNAME: 
First name: 
Middle name(s)

Full name & address of permanent Institution : 

Tel. No.:
Cable: 
Telex: 
Telefax:
Electronic mail address:



Full name & address of present Institution  (if different from permanent): 

Tel. No.:
Cable: 
Telex: 
Telefax:
Electronic mail address:
Temporary address valid until:

Expected Arrival Date at ICTP:
Expected Departure Date from ICTP:

Scientific activities taking place at the Centre during your visit which are 
of relevance to your researchprogramme or scientific interest.

Field of Research: Kindly  specify  below (using a maximum of 150 characters) 
your current main resesarch topics:

Research programme you plan to carry out during your visit to the Centre. 
Your plans/desires as to writing papers/preprints. Recent research work 
you have been doing in your country (list your publications related to 
the above work,if any).


Signature:                      Date:

IMPORTANT PLEASE SEND CONFIRMATION OF YOUR VISIT DATES TO THE ASSOCIATE SCHEME OFFICE THREE MONTHS PRIOR TO YOUR ARRIVAL DATE AT ICTP (AS INDICATED ON THIS FORM). INVITATION LETTERS ARE SENT ONLY AFTER RECEIPT OF THIS CONFIRMATION.  KINDLY NOTE THAT ONCE THE INVITATION LETTER HAS BEEN
ISSUED, ONLY ONE CHANGE IN YOUR VISIT DATE WILL BE CONSIDERED, 
BEFORE YOUR VISIT IS AUTOMATICALLY CANCELLED.

FOR FEMALE ASSOCIATES ONLY: 
SHOULD YOU BE PREGNANT AT THE TIME OF YOUR VISIT, PLEASE PROVIDE US
WITH A MEDICAL CERTIFICATE STATING CLEARLY YOUR EXPECTED DELIVERY DATE.


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