International  School of Liquid Crystals  
                         12th Course
                 1st NAIMO Summer School on:
   
 Nanoscale self-organizing multifunctional organic materials
   
         Erice (Italy), 24 September - 2 October 2005 
 
                      APPLICATION    FORM 
Surname.......................................................    
Name..........................................................    
Date and place of birth.......................................    
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Degree and other academics qualifications.....................
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Address.......................................................    
Zip.................. City....................................    
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Tel..............................Fax..........................    
E-mail........................................................    
Current research interests....................................
..............................................................    
I am willing to present a contribution (poster only) 
                                                yes [ ] no [ ]
Tentative Title: .............................................
..............................................................

To be sent, preferably via e-mail, to orlandi@ms.fci.unibo.it and
pasini@bo.infn.it
or via FAX to Dr. P.Pasini at the no. +39 051 244101.

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