International Programs

Australian Academy of Science Scientific visits

Summary sheet

(All fields must be completed)

1. Program: Sub-program

2. Proposed country

3. Address details

Title
First Name
Last Name
Position
Organisation
Other
Application sector
Department
Street Address
Suburb
State Postcode Country

4. Contact details

Phone (work) Phone (mobile)
Fax
Email

5. Date of birth

Day / Month / Year

6. Name and address of main host

Title
First Name
Last Name
Position
Organisation
Department
Street Address
Suburb
State Postcode
Country
Email
Phone (work) Phone (mobile)

7. Brief title of proposal

General

1. Please select your field of science from the following list

2. Please select the most relevant National Research Priority that your research falls under

3. Where did you find out about the Academy's program?