Application Form for the 2012 ICO Award

I apply for the 2012 ICO Award.

First name:	
Second name:	
Family name:	
Nationality:	
Month/year of birth: 	/
Affiliation:	
Title of your presentation:	
Author(s) of your presentation:	/     /
Date of application:	/     /

During the Congress the screening committee selects the best presentation(s) of the session speakers and the poster presenters of the ages under 40 (those who were born on August 1, 1971 or later), and gives the '2012 ICO Award' at the closing ceremony of the congress.
The members of the screening committee will be commissioned by the Chair of the Organizing Committee before the opening of the congress. 
Those who wish to apply to this competition, please fill the application form and then send it to the Congress Secretary:

Hidenori Ubukata
intodon2012[at]gmail.com [at]=@