HRIBF Workshop Registration: Fusion-Fission


Welcome to the on-line registration form for HRIBF Workshop Registration: Fusion-Fission. This is a secure document; your browser should indicate this by a closed padlock icon. Receipt of your registration will be confirmed via email prior to the workshop.


You are expected to provide for your own travel and hotel reservations. Limited space is available in the dormitory. We ask for a contribution of 20 USD (cash only) to offset the costs of lunches and coffee breaks.

If you wish to present something, send a 1-page abstract (pdf) to Dan Shapira at shapira@phy.ornl.gov

Time it takes to process your request to come to ORNL.
Nationality This workshop
U.S. Citizens August 29
Citizens from other countries August 5


Personal information
Last (family) name

First name

Middle name(s) (all other names in passport)

email

Telephone

Fax

Gender
        Male         Female
Institution, university, laboratory, business, etc.

Street Address or department and mailstop

Street address (cont)

City

State/Province (only if part of mailing address)

Country

Postal code


As a consequence of the strong magnetic and rf fields present at the HRIBF, there are some potential health hazards associated with visiting Building 6000 where the accelerators are housed. If you wear a pacemaker for your heart, please inform us prior to your visit.

Please supply this additional information about yourself.

Date of Birth (MM:DD:YY)

Citizenship

U. S. Social Security Number (write NA if you do not have one)
Arrival Date at ORNL (MM:DD:YY)

Departure Date from ORNL (MM:DD:YY)

Additional information required of non-citizens of the U.S.

Passport Number

Passport Expiration Date (MM/DD/YY)

Visa Type

Visa Expiration Date (MM/DD/YY)

Visa number (if permanent resident alien)

Are you presently in the USA?
        Yes         No
City and Country of Birth

Highest University Degree and Subject

Date of Degree

University Granting Degree

Present job position title
You must also fax us a copy of the page in your passport which contains your name, place of birth, etc. Often, passports which have dark or colored backgrounds do not fax well. In these cases, you will be asked to scan your documents and send them as an email attachment to Ms. Sherry Lamb at lamb@phy.ornl.gov.
Our fax number is +1-865-576-5780.

Please review all the information above and, if correct, submit the form.


For more information or assistance, please contact the Workshop Contact.

This information was last updated on May 6, 2005 .