Workshop on Macroscopic Modeling of Materials with Fine Structure

Items marked in gold are required

First Name(s):

Family Name:

Address:

Telephone:
E-mail:

Badge: Name and Affiliation:

Postdoctoral Fellows:

Current Institution:
Research Interests:
Name of Mentor:

Graduate Students:

Anticipated date of Ph.D.:
Institution granting the PhD:
Name of Advisor:

Postdoctoral fellows and graduate students: Would you like to be considered for financial aid for travel? No Yes
The deadline for financial aid is March 1, 2011.

Further information:

Period of visit:

From: Month Pick Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day Pick 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Dorm Housing: None Single Occupancy Preferred Double Occupancy Preferred

For housing purposes, please indicate your gender: Male Female

Would you like to give a contributed talk? No Yes
The deadline for submission of contributed abstract is March 1, 2011.

If yes, please submit the title and abstract.
Title:
Abstract (text or TeX):

Would you like to present a poster? No Yes

If yes, please submit the title of the poster:
Poster Title:

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