| Institution (*): | 
           | 
        
        
          | Department (*): | 
           | 
        
        
          Description:  
            (Optional text you wish to use to 
            describe your institution, or any other  
            comment. This is not saved to the  
            database but might be useful in 
            processing the form.) | 
           | 
        
        
          | Head of the Department:
             | 
          Title: 
            
             
            First Name (*): 
             
            Last Name (*): 
             
            Head's E-Mail (*): [Note: Department's general e-mail
            has a separate field.] 
             | 
        
        
          Address: 
            (Enter 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: | 
           | 
        
        
          Number of Academic
        Teaching  
        and Research Staff:  | 
          Full Time: 
            Part Time:  | 
        
        
          Contact: 
            (Enter your name or the name  
 of the person
            responsible for  
 maintaining information submitted  
            to Education Database.)  | 
         	Name: (*) 
               
              Contact e-mail (*): 
               | 
        
        
          Internet path for a logo:  
            (to be used in the Education Database  
            to identify your organization; max. width 
            and height 300 x 100 pixels) | 
         	 |