Fiche_Accueil | L3i-PN

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- ATTENTION : le formulaire ne doit pas comporter de caractères spéciaux ou accentués

Personal information:

Last name*:

First name*:

Gender*:

Man

Woman

Photo*:

Phone number:

Mail address*:

Birth date (For Safari, use the format yyyy/mm/dd)*:

Address in La Rochelle :

Degree obtained (The highest)*:

Degree in progress (specify the year: 1st, 2nd or 3rd) :

Current status*:

Home institution :

Information about stay

Mission or project*:

Stay start date (For Safari, use the format yyyy/mm/dd)*:

Stay end date (For Safari, use the format yyyy/mm/dd)*:

Special needs: Machine (with desired operating system), etc*:

Funding L3i :

Type of stay at L3i*:

Supervisors (At least 1)*: