APPLICATION FORM

Euroleague for Life Sciences

Summer School 2017
Pathogens, Parasites and their Hosts:
Ecology, Molecular Interactions and Evolution
University of Hohenheim
3 July 21 July 2017
Please complete in BLOCK LETTERS and send this form to:

Dr. Gabriele Klumpp,

Euroleague for Life Sciences (900)
University of Hohenheim, Fruwirthstr. 12, D-70599 Stuttgart, Germany
gabriele.klumpp@uni-hohenheim.de
Application deadline: 31st March 2017 or until places are filled

Personal data
Family name:
First name(s):

Male:

Date of birth:
(date/month/year)

Nationality:

Female:

Current address
Street and No.:
Telephone No.:

E-mail:

Postal code and city:

Country:

Academic profile
Degree presently pursued / Major field(s) of study:

University

Month and year of enrolment:

Language proficiency in English:

Indicate level:

Poor

Moderate

Good

Motivation for participation in the intensive summer university. Relevant prior studies/
academic background:

Signature of applicant
I wish to apply for the ELLS Summer School Pathogens, Parasites and Hosts 2017 at the
University of Hohenheim. I hereby confirm that the above information is correct.
I have been informed that I have to ensure adequate health insurance during the duration of the
programme.
Date:

Signature:

For students from abroad

Alternative/Parents address (July 2017)
Street and No.:
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Country:

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Fax No.:

E-mail:

Contact person in case of emergency

Name:

Relationship:

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