Application form a.a.2004/2005

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structure
specializations
courses
governing bodies
events

information
application form

intranet

italian edition

Address
This address will be used for all subsequent communication.
First Name	Last Name
Street and Number
Post Code	City
Country	Phone (with full code)
Fax (with full code)	Mobile (with full code)
E-Mail Address (only one)

Candidate Profile Information
All information given will be treated in the strictest confidentiality.
Date of Birth	Nationality
Faculty	University
Last Degree	Specialty
Graduation Date	Degree Mark or Class
Final Dissertation Title
Current Profession (possibly)	Baccalauréat Year
Baccalauréat Nature	Mark or Class ("Mention")

High School Studies (year by year)
Please specify: Year, Level, Institution, Result and Mark or Class

Professional Experience

Other Information

Specialization

Multichannel Communication : Content Design
Multichannel Communication : Management and Technology

I declare on my honour the exactness of all informations mentioned above and I undertake to present the originals of diplomas and certificates of marks if my candidature is selected by the scientific committee. Any erroneous mention entails the cancellation of my candidature.

This registration form must be sent by January 31, 2005 for the Tunisian candidates and February 8, 2005 for other candidates.
The preselected candidates will be invited to an interview.
Note: please do not use inverted commas (") when filling in the form.

Application form a.a.2004/2005

Address

Candidate Profile Information

Specialization