1. Contact information

   Name: 
   Address: 
   Telephone:
   Email: 
   Homepage:

2. If the above is not permanent, please provide your permanent
   address and/or telephone number:

3. Do you mind if the above contact imformation is published on the 
   World-Wide Web without password protection?

4. Field of study:

5. Dates of receiving the Croucher Foundation Scholarship and/or Fellowship
   (please specify): 

6. Are you interested in joining the Croucher newsgroup?

7. Are you likely to be able to join the Welcome Meeting for new Croucher 
   Fellows and Scholars which is usually held in the UK some time in 
   September or October?


After completing this form, please email it to wl@doc.ic.ac.uk