EURACHEM APPLICATION FORM

EURACHEM ANALYTICAL MEASUREMENT COMPETITION

EAMC 2004 APPLICATION FORM

Complete this form in Block Capitals and forward it to your Head of Department by early January.

Name: _________________________________________ Year of Study:______

Your Institution: ______________________________________________________

Dept & Title of Course:_______________________________________________

Tick your main area of specialisation: Biology Chemistry Physics Other

Home Address: ________________________________________________

& contact phone no.

________________________________________________

Term-time Address (if different)_________________________________________

& contact phone no

______________________________________________________

e-mail address:______________________________________

I wish to apply for selection to represent my institution in the Eurachem Analytical Measurement Competition and I agree to bound by the rules of the competition.

Signature:________________________________ Date:______________

For Head of Faculty/School/Department

Our above-named student has been ranked __________ in our selection procedure

and has been chosen to represent _______________________________________

in the EAMC competition.

Signature:________________________________ Date:______________

Capacity/Position:_________________________________

Telephone:_______________Fax :______________ e-mail ___________________

The signed form should be forwarded to EAMC Entry 2004, State Laboratory, Abbotstown, Castleknock, Dublin 15, together with a Postal Order or cheque (payable to Eurachem Ireland) for €50 per team, by 20th Feb 2004.