MR or Ms *:
Last Name/ Appelido/Nom* :
First Name/Nombre/Prénom* :
Title :
Professor/Lecturer/Teacher
Researcher/Writer
Phd/Master Student
Other or none
University Grade :
Doctor
Master
Other or none
Discipline Speciality* :
(official for teaching / research /writing or let in blank)°
Position :
Head/Director
President
Other (specify)
Position Other :
Institution (category) :
University/College/High School
Research/Studies Center
Non Profit Org.
Enterprise
International Org.
Other
Full Postal Address :
Including name of institution, ZIP Code, and Country
Tel N° :
FAx N° :
E-mail address :
Additionnal e -mail address
Or/and Home page url :
City* :
Country* :
Preferred Language :
English
French
Spanish