================== APPLICATION FORM ================== I would like to attend the European Conference on Dynamics of Molecular Systems (MOLEC-17) to be held at St.-Petersburg, Russia, on August 23-28, 2008. Please mark: I need a Letter of Visa Invitation I do not need a Letter of Visa Invitation VISA INFORMATION ************************* 1) // Title/Status (Prof, Dr, Student, Accompanying dependent, ...) // ----------------------------------------------------------------------------- 2) // Family Name // ----------------------------------------------------------------------------- 3) // First name, other names, patronymic (if applicable), as it appears in your passport // ----------------------------------------------------------------------------- 4) // DOB (dd.mm.yyyy), place of birth // ----------------------------------------------------------------------------- 5) // Sex (Male, Female) // ----------------------------------------------------------------------------- 6) // Citizenship // ----------------------------------------------------------------------------- 7) // Passport number, expire date // ----------------------------------------------------------------------------- 8) // Name and DOB of accompanying children below 16 (if they are mentioned in your passport) // ----------------------------------------------------------------------------- 9) // Approximate dates of arrival to and departure from Russia // ----------------------------------------------------------------------------- 10) // Russian Consulate where you intend to apply for a visa // ----------------------------------------------------------------------------- 11) // Address, phone number // ----------------------------------------------------------------------------- 12) // E-mail // ----------------------------------------------------------------------------- 13) // The FAX number where the VISA invitation should be sent // ----------------------------------------------------------------------------- ************************** SCIENTIFIC INFORMATION ************************** Research field: ____________________________________ Affiliation: _______________________________________ _______________________________________ Address: ___________________________________________ ___________________________________________ Zip/Post Code: ____________________________________ City: _____________________________________________ Country: ___________________________________________ Telephone: ____________________________________ Telefax: ____________________________________ E-mail: ____________________________________ If you would like to make a presentation at the meeting then please complete the following: I would like to give a talk entitled _________________________________________________________________ _________________________________________________________________ Author(s) (please underline the speaker) _________________________________________________________________ _________________________________________________________________ I would like to give a poster entitled _________________________________________________________________ _________________________________________________________________ Author(s) (please underline the presentator) _________________________________________________________________ _________________________________________________________________ Comments or suggestions: ___________________________________________________ ___________________________________________________ Date: Signature: