| 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 (*):  | 
         	
               |