REQUEST FOR PARTICIPATION

First School of Cosmic Ray Physics and Astrophysics,
La Paz - Bolivia, 9 - 20 August 2004
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P E R S O N A L   D A T A

FAMILY Name:  
MAIDEN Name (For women only):
First name:	
Middle name(s):        
Sex:
Nationality:	    
Academic Degree: 

Full name/address of Institution:

Tel. No.
Fax No.
E-mail:  		

Home address:				

Tel. No.
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Mailing address:        Institution:   Home: 


REQUEST FOR FINANCIAL SUPPORT

Important:  Because our 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 (Please tick ONE box only.)

Full Travel 
Subsistence only
Half Travel + Subsistence
No financial support requested

It would be of assistance to the Selection Committee if this request for Financial support were accompanied by a letter of recommendation, especially for junior physicists,