| Organisation (*): |  | 
        
          | Department (*): |  | 
        
          | Address: (Enter the three main lines for the
 address, e.g. faculty/department
 and the street address)
 | 
 
 | 
        
          | City / State (if applicable): | State: | 
        
          | Post Box (if applicable): |  | 
        
          | Postcode: |  | 
        
          | Country (*): |  | 
        
          | Telephone: (include country code,
 e.g. +1 for United States)
 |  | 
        
          | Fax: (include country code,
 e.g. +1 for United States)
 |  | 
        
          | Department E-mail (*): |  | 
        
          | Web: |  | 
        
          | Head of the Department: | Title: 
 First Name (*):
 
 Last Name (*):
 
 | 
        
          | Number of Academic
        Teaching and Research Staff:
 | Full Time: 
            Part Time: | 
        
          | Details: (Please attach a brief description
 of your organisation/department's
 field of activity, including details
 of courses.)
 |  | 
        
          | Contact (*): (Enter the title/position and
 name of the contact person.)
 |  | 
        
          | Contact E-mail (*): |  |