APPLICATION FORM

Participation in (part of) the programme can be applied for by completing and signing this form, and submitting it at least one month before the beginning of the module(s) concerned:

Postgraduate Education in Toxicology

Wageningen University

P.O. Box 8000

NL-6700 EA Wageningen

The Netherlands

This form must be accompanied by a brief curriculum vitae, which should include your present address, place and date of birth, scientific training, work experience and present employer.

Should the number of applications exceed the capacity of the programme, the PET Advisory Committee will select applicants on the basis of previous training and/or work experience.

You will be informed in writing whether you have been accepted into the programme and how to pay the tuition fee.

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I, the undersigned, hereby apply for the PET programme.

I wish to participate in

O the whole programme (which includes 17 courses)

O the following module(s) (please indicate the year of participation):

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Name:

Address:

Telephone:

E-mail:

Date: Signature: