2009-Social Cognitive Neuroscience

PERSONAL DATA
	All Personal Data MUST BE PROVIDED by Conference Chairs, Co- or Vice-Chairs, Discussion Leaders/Session Chairs, Speakers and Applicants.

Title:	DameDr.LadyLordMr.Mrs.Ms.ProfessorSir
Family name:
First names:
Nationality:	AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBéninBermudaBhutanBoliviaBosnia and HerzegoviniaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChiliChinaChristmas IslandsCocos (Keeling) IslandsColumbiaComorosCongoCongo, The Democratic RepublicCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDemocratic People's Republic oDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslaHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIslamic Republic of IranIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOccupied Palestinian TerritoryOmanPakistanPalauPanamaPapua New GuineaParaguayPeople's Democratic Republic oPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of KoreaRepublic of MoldovaRéunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South SaSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanThailandThe Former Yugoslav Republic oTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited Republic of TanzaniaUnited StatesUnited States Minor Outlying IUruguayUS Virgin IslandsUzbekistanVanuatuVenezuelaViet NamWallis and FutunaWestern SaharaYemenYugoslaviaZambiaZimbabwe - Other -
Date of Birth (dd/mm/yyyy):	Example: 25/10/1964
Sex:	Male Female

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Work Address:	This is the address which will be used for all correspondence. Please be precise and do not repeat the same information in several fields! Also do not use capitals in a systematic way. Ex: University, and not UNIVERSITY
Organisation: or	(for Companies, Journals, Foundations, Ministries, Associations...)
University:
Faculty:	(for Faculty, Institutes, Schools...)
Department:	(for Dept., Division...)
Address:	(for street, etc.)
Addr. continued:	(P.O. box, etc.)
Postcode/Zip code:	(Enter it here only if postcode should appear before the town on an address label, otherwise use "Region" field below)
Town:
Region:	(for UK codes, US state and zipcodes, Cedex, etc.)
Country:	AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBéninBermudaBhutanBoliviaBosnia and HerzegoviniaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChiliChinaChristmas IslandsCocos (Keeling) IslandsColumbiaComorosCongoCongo, The Democratic RepublicCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDemocratic People's Republic oDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFederated States of MicronesiaFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslaHoly See (Vatican City State)HondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIslamic Republic of IranIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOccupied Palestinian TerritoryOmanPakistanPalauPanamaPapua New GuineaParaguayPeople's Democratic Republic oPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of KoreaRepublic of MoldovaRéunionRomaniaRussian FederationRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South SaSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanThailandThe Former Yugoslav Republic oTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited Republic of TanzaniaUnited StatesUnited States Minor Outlying IUruguayUS Virgin IslandsUzbekistanVanuatuVenezuelaViet NamWallis and FutunaWestern SaharaYemenYugoslaviaZambiaZimbabwe - Other -
Telephone:		Please enter Phone and Fax in format: +Country-code Area-code Number.
Telefax:		Example: for Munich, Germany: +49 89 783850 for Austin, USA: +1 512 4710317
E-Mail:

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VISA : To which Embassy/Consulate will you apply for a VISA?

Please indicate full address in box

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Workplace :

Academic Organisation
Industry (paying for own conference fee)
Other (specify):

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STATUS:	Applicant Chairperson Vice-Chairperson Speaker

Presentation : (does not concern invited speakers)

I do not wish to present anything
I wish to present a Poster
I wish to present a Short talk:

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Accommodation

Indicate which accommodation you would prefer if you are accepted (requests will be satisfied on the basis of room availability and accepted participants will be asked to register and confirm their requirements) :

No room needed
Single Room
Twin Room (1)
Willing to share a twin room (if only few singles available)
Double Room (2) => Number of guests (yourself not included):

(1) With another participant
(2) With accompanying guest(s)

APPLICATION
.	The data below need NOT be provided by Conference Chairs, Co- or Vice-Chairs, Discussion Leaders/Session Chairs and Speakers  Please use plain text only: no LaTex, no graphic files, no symbols, no enriched text (bold, italics,underlined, ...)

ABSTRACT of the poster you wish to present: (equivalent to one A4 page max.!)
	Title of the abstract, author(s)  and affiliation:
	Text of the abstract:

RESEARCH INTERESTS

Key words describing your current research (not required from speakers) in less than 200 words:

PUBLICATIONS
Please give a short list of your recent publications (not required from speakers) relevant to the subject area of the conference - maximum 10 references

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EDUCATION:

I obtained or I will obtain my doctoral degree on:  (specify date less than 10 years prior to, and 18 months after,  the event)	(dd/mm/yyyy)
Note for invited speakers only: -> this field cannot be left empty in order to submit the form. Kindly either indicate the date of your doctoral degree or enter any date.

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FOR THE ATTENTION OF YOUR RESEARCH SUPERVISOR:

(students only):

I support this application of attendance at this European Research Conference.

Name of supervisor:
Date and place:
E-mail of supervisor:

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Thank you for your feedback on the points below...

1. How did you first learn about this conference:

Select... 01. received the programme of all conferences through the post 02. received the preliminary programme for this conference through the post 03. saw a poster of the full programme of conferences displayed in my lab 04. saw a poster of the poster for this conference displayed in my lab 05. a colleague (or supervisor) told me about it 06. I am an invited speaker 07. received an e-mail from ESF 08. saw an advert in Nature 09. saw an advert in an Elsevier publication 10. saw an advert in other journal 11. saw it on the ESF web server 12. saw it on another web server 13. other means

2. Which journal do you read most often:

Nature
Science
Both
Other: 

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This Application Form is designed to enable us to transfer most of the data directly into the ESF database.
So please take the time to check that the information you are about to submit is correct and properly entered as you will not be able to modify it on-line after pressing the "Submit" button.
Thank you for your understanding.

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Submission...	may take a few minutes as the data will first be checked on YOUR computer before being sent to our server. Click only once on the submit button and WAIT. A summary form of your application will be displayed after submission. We recommend you to print out this summary  form and keep it as a record of your application.

Applicants will be informed 6-12 weeks prior to the conference of the outcome of their application.

In accordance with European directives and with French Law No. 78-17 of January 1978 on information processing, electronic files and civil liberties you have a right to access and update the personal information about you, ask for it to be modified, deleted etc. This right may be exercised by sending a message to database@esf.org Information is gathered within the framework of the management of our activities and to this end some information may be passed on to third parties in France or abroad. Further information on the collection, registration and dissemination of data is available at http://www.esf.org/data.