International School on Nuclear Physics, 27th Course
   "Neutrinos in Cosmology, in Astro, Particle and Nuclear Physics"  
        Erice, Sicily, Italy, September 16 -- 24, 2005

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                    First Questionnaire


     1. Family name, Title:


     2. Given name:
        Age:         F/M (female/male)


     3. Institution:


     4. Street:


     5. Town, Zip Code:

       
     6. Country:


     7. E-mail (preferably internet):

 
     8. Phone:
        Fax:

     9. I want to receive further information   Yes/No
       

    10. I want to participate in the school     Yes/No 


    11. I want to give a seminar talk           Yes/No 


    12. Title of your seminar or invited lecture:


    13. Recent research interests close to the subjects of the 
        school:



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    Letter to the organizers (optional; use below as much space as you need):

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    send preferably by e-mail to:   erice2005@uni-tuebingen.de

    or by normal mail to:  Mr Burghard Grueter
                           Institut fuer Theoretische Physik
                           Auf der Morgenstelle 14 
                           D-72076 Tuebingen
                           GERMANY