484th WE-Heraeus Seminar: 
Physics of Biological Function - Multicellular Systems,   December 12-15, 2011
- Application form -
Please email to   Ms. Caroline Lesperance: caroline.lesperance@physik.lmu.de

Name: _____________________________________
Email: _________________________________________________
Affiliation: ______________________________________________________
Address: _______________________________________________________
Status: 	☐  Student	   ☐  PhD student    ☐  Postdoc    ☐  Group leader
Field of work: ___________________________________________________
Academic advisor (if applicable): ____________________________
Do you wish to present a poster ?      	☐  Yes        ☐  No
If so, indicate topic of poster: _______________________________________
_______________________________________________________________
If you already have publications related to the topic of the workshop, please indicate the most relevant:
_______________________________________________________________
Planned duration of your stay?  Arrival: __________  Departure: ___________