APPLICATION FORM

34th Microelectrode Techniques for Cell Physiology Workshop

Application deadline 31 March 2017

Title / Surname / First Name(s)
Gender / Nationality / Date of Birth

Please tick for yes

☐PhD student

☐PostDoc

☐Require visa supporting letter for UK entry

If yes, please give Passport No and Place of Birth:
☐Wish to be considered for a bursary to assist with the fee

If yes, a bursary application will be sent to you should you be selected for the Workshop

☐Affiliate Member of the Physiological Society

☐ I am happy to be included with email contact details on the participant list provided to all workshop students, Speakers, teachers and invited companies.

Company / Organisation / Educational establishment you belong to
Your preferred correspondence address for postal mail
Email address
Contact telephone number
Including country prefix
Supervisor name
Supervisor email address
Your current funding body
Any special dietary requirements
List in order of priority four techniques that you would like to learn selected from the below:
-Two electrode voltage clamp
-Patch clamp –single channel, whole cell, slice recording
-Single electrode voltage-clamp
-Dye injection
-Ion-selective microelectrodes
-Fluorescent indicators / 1st
2nd
3rd
4th

Please submit this application form by email, attaching your:

Curriculum Vitae

Research Project Giving a concise description of your research, your reasons for wishing to attend and your experience of techniques taught on the course. Maximum length 4 pages.

Letter of Recommendation On organisation letterheaded notepaper, signed by an academic referee - preferably PhD supervisor or Head of Laboratory. This letter should indicate how your research, the laboratory in which you work and the area of research that you intend to pursue will benefit from your participation on the course.

Please send these four documents to arrive no later than 31 March 2016: All applications will be acknowledged by email on receipt. If by 3rd April you have not received an email confirming safe receipt, please telephone 0044 (0)1752-426540, ask for Paul Lonsdale or Alex Street.