Title: New Members Registration
Author: Nirisha
Company: NS

Fluorescence Applications in Biotechnology and Life Sciences - New Members Registration Form

Personal Information

Title*: _______   First Name*: __________________ Last Name*: _____________

Website: ____________________________________________________________

Organisation: ________________________________________________________

Department:  ________________________________________________________

Highest Qualification*:______________________ Year Awarded*:______________

GAMS ID: ___________________________________________________________

Contact Information

Email*: ______________________________________________

Phone Numbers:

Home: Country Code: _____  Area Code: _____  Phone #: ___________ Ext: ____

Work:  Country Code: _____  Area Code: _____  Phone #: ___________ Ext: ____

Fax   : Country Code: _____  Area Code: _____  Phone #: ___________ Ext: ____

Mobile: _____________________________

Postal Address:

Street: _____________________________________________________________

City: _______________________________ State/ Province: __________________

Zip/ Postal Code: _____________________ Country: ________________________

Reason to Join

It is important for us know how the Network can best serve your interest. Please kindly state your reasons for wishing to join the Network.

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___________________________________________________________________

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Please send the completed form to:
A/Prof. Ewa M. Goldys
Director, Optical Microcharacterisation Facility, 
Division of Information and Communication Sciences
Macquarie University, NSW 2109, Australia

Or email to: goldys@ics.mq.edu.au