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Application Form: 4th German Collaborative Summer School in Epidemiology

I hereby apply for the Summer School Complexity

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Personal information

* Pflichtfeld

Title
First Name*
Last Name*
Date of birth (dd.mm.yyyy)*
Nationality*
Mailing Address*
E-Mail*
Telephone
DGEpi	DGEpi member.
ARI	Member of the Academic Research Institution.

Education / work experience

* Pflichtfeld

Highest attained degree*
if other: please specify
Degree: Major
Occupation
Employer
Other relevant qualifications

Fee according to participant status

Participants from for-profit organisations or others
Participants from academic & research institutions
DGEpi members
Fulltime students
Please give us a short information about the dates you plan to attend the event (e.g. Monday, Tuesday)

Please transfer the registration fee as soon as possible (the number of participants is limited) to

University of Munich
Account number: 24868
Bank number: 700 500 00
Bank: Bayerische Landesbank

IMPORTANT: You must specify the following reference number!

Reference number: Kapitel 1507, TG 77, AOSt 731190-5, BKZ 4200.0276.8108
and Your full name

For international transfer of the registration fee you may use the following IBAN number:DE53 7005 0000 0000 0248 68 and the BIC-code: BYLADEMMXXX

Please note that your participation is only binding after the complete payment of the registration fee.

Scholarship

- I am a LMU student and apply for the scholarship for LMU students.
Motivation to study this course

Certification

* Pflichtfeld

- Thereby I certify that all information provided above is correct and complete

Attachments

Only for students:
- Please attach a scan of your matriculation papers or student ID (Studienausweis):
max. Dateigröße: 11 MB
nicht erlaubte Dateitypen: EXE BIN

Datenschutz

Die Informationen zum Datenschutz sind in der Datenschutzerklärung der LMU abrufbar.

Ich bin mit der Datenverarbeitung zur Bearbeitung der Kontaktanfrage einverstanden.*

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