Invoice No: Date received:

VILNIUS UNIVERSITY
and
THE TAVISTOCK INSTITUTE OF HUMAN RELATIONS

EFFECTIVE COLLABORATION –
ROLES, MOTIVATIONS & RISKS

20TH - 24TH AUGUST 2011

APPLICATION FORM

Please fill in the information requested below

Surname: ………… ………………………………….………Title: Mr / Ms / Mrs / Dr

Forename(s) …………… ………………………………...…..Age: …………….…..…….

Male / Female ……………………..

Employing Organisation ………………………………………..…………………………….

Official Title of Present Post: …………………………………….…………………………..

Work Address: …………………………………………………………………………………

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Tel No: …………………………………………… Mobile: ………………………..…..

Email: ……………………………………………… Website: ……………………..……

Private Address:
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Tel No: ……………………………..………………… Email: …………………..…………..

Preferred address for email: work / private posted mail: work / private

1
 I want to order lunches for all programme days Yes / NO
(The price of lunch is 20 Lt.)

To reserve your place:

Please return this application form:

Vilma Kuodyte
E: vilma.kuodyte@fsf.vu.lt
T: +370 5 2667610, mob: +370 672 99216

The conference fee has to be paid after the application admittance of Programme
Directorate. The conference fee has to be paid before the deadline for
applications (the 5th August 2011), or the fee with Early bird discount has
to be paid before the 30th June 2011. Receipt confirming the transfer has to be
sent by email.

If you want to apply for the bursary you will be asked for additional information.

Signature:

I have read the brochure for this programme in detail and apply to become a member. I
understand that this brochure constitutes the contract between the University of Vilnius and
myself and that my application authorizes the organization to conduct the programme in the
manner described.

Signature of applicant: …….…..…………….…..................... Date: ……………………