IME-NANOMXCN Sponsorship Form

(Use this form ONLY if you are a Mexican National leaving outside México applying for the IME-NANOMXCN Sponsorship)

To register, please complete this form and return it to NANOMXCN Secretariat () before 20 Nov 2016. NOTE: Early registration deadline: 15 Nov 2016

Title: ______First Name: ______Last Name______

Organization:______Position: ______

Address: ______

State: ______Zip Code______Country: ______

Tel.: ______Mobile: ______Email: ______

For presenters only, in line with NANOMXCN’s aim to reach widespread audience interested in fostering collaboration opportunities we will seek to broadcast/disseminate the presentations via internet please indicate:

☐ I agree that my presentation can be recorded and be available online to all

☐ I agree that my presentation can be recorded and be available online if password protected

☐ I do not wish my presentation to be recorded

All personal data provided to the Organizer for registration will be treated as confidential. The data shall be used and stored for further processing and documentation purposes. The information will not be re-used for an incompatible purpose.

NANOMXCN organizers reserve the right to modify the content of the program, the speakers, and the times of presentations.

FINANCIAL SUPPORT

Three grants of 1,500 euros each will be granted to selected participants, as a contribution towards the registration fee and travel costs on the following basis:

·  All other costs are the sole responsibility of the applicant. The applicant must submit proof of financial solvency: there is not template, suggested documents are: letter from line manager, sponsorship letter from third party, others as deemed appropriate.

·  Contribution on a reimburse basis provided the awardee i) pays registration fee before the Early Registration deadline and ii) participates on the complete workshop and work trip (4 to 11 Dec 2016).

Contact and Requests

Conference Secretariat: Tel: +(852) 3442 5683 Email:

Department of Physics and Materials Science, City University of Hong Kong

IME-NANOMXCN Sponsorship Form

Signature: / Date:

I hereby declare that I understand the basis of IME-NANOMXCN Sponsorship and that I have funds to cover all other costs resulting from my participation on the full program 4-11 Dec 2016.