Second semester of the UNESCO Chair at LAMSIN HISTORY OF MATHEMATICS Tunis, October 4th- December 17th 2004 APPLICATION FORM Surname/Family Name : First Name : Date of Birth : (year-month-day) Present Nationality : Full name and address of permanent institution : Full name and address of present institution : (if different from permanent) Home address : Mailing address : Academic qualification(s) and Year of qualification(s) obtained : Kindly supply a keyword description of your current scientific activities (area of research, specific topics of interest, list of publications...) Mention briefly your previous research experience and explain your reasons for wishing participate to this activity : Yours referees ( Name and addresses )(*) : (Send to Marouane Ben Miled : marouane.benmiled@fss.rnu.tn) (*) The referees will be contacted at the email addresses that you provide. Be absolutely certain that they are correct.