APPLICATION FORM Euroleague for Life Sciences - Summer School 2017 “Analysis and utilization of genomic diversity for plant breeding” 6 - 12 August 2017 University of Hohenheim, Stuttgart, Germany Please complete this form on your computer, sign it and send a scanned version of the signed form to: [email protected] Dr. Gabriele Klumpp Euroleague for Life Sciences (900) University of Hohenheim, Fruwirthstr. 12, D-70599 Stuttgart, Germany Application deadline: 31st March 2017 or until places are filled Personal data Family name: First name(s): Male: Place and date of birth (day / month / year) 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: Planned date of completion Language proficiency in English: Listening/speaking: O basic O moderate O good Writing: O moderate O good O basic Female: 2 Motivation for participation in the intensive summer university: Relevant prior studies/ academic background: List and describe especially those courses you already passed in the field of plant genetics, plant breeding and/or statistics. Describe why you consider this course important for your further study and career. Describe your thesis title and topic and name your supervisor (if applicable) Signature of applicant I wish to apply for the ELLS Summer School “Analysis and utilization of genomic diversity for plant breeding”, 6 - 12 August 2017. 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: 3 For students from abroad Alternative/Parents address (August 2017) Street and No.: Postal code and city: Country: Telephone No.: Fax No.: E-mail: Contact person in case of emergency Name: Relationship: Street and No.: Postal code and city: Country: Telephone No. (Private/ Work) Fax No.: E-mail: