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IMA General Membership Application Form

Thematic Year:

Please submit the following documents together with the application form:

Curriculum vitae including list of publications.
Personal statement describing scientific interests, research plans, and reasons for wishing to participate.
Name and email address of reference letter writer:
NameEmail

Application Form:
Last Name:
First Name(s):
Current Position:




Home address:
Office address:
Home phone:
Office phone:
E-mail address:
Date Ph.D. received or expected:
Ph.D. Institution:
Ph.D. Field:
Gender:
Race:






Citizenship:



Give the proposed start and end dates of your visit. Residency should fall in the period September through June of the thematic year. Extension into the preceding or following summer may be requested if justified.
Proposed start date:
Proposed end date:
Number of months of local expense support requested:
Describe other support you will be receiving or have applied for:
                            
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