Course Registration Form

Intensive Course "WMD Nonproliferation and Security for Women in STEM" (Rabat, Morocco, March 9-13, 2020)

Please complete all sections. Compulsory fields are marked with asterik (*). Leave blank the fields that do not apply to you. Your information will be kept strictly confidential. If you have questions or need assistance, please email Margarita Kalinina-Pohl: mkalininapohl@Middlebury.edu.
Name*

First NameMiddle NameLast Name
Birth Date*

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E-mail (where course organizers can reach you)*
Gender*
Country of Residence*
Nationality*
Address*

Street Address

Street Address Line 2

CityCountry

Postal / Zip Code
Mobile Number*

Area CodePhone Number
Work Number

Area CodePhone Number
Current Employer Name and Address*
Current Job Title*
Type of organization*

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Your primary job responsibilities*
Level of Education*

Undergraduate (Batchelor)Graduate (Master)Post-Graduate (PhD)Other
Area of study/ expertise
Length of your employment

0-5 years6-10 years11-15 years16 and above
English Language Proficiency*

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How would you or your organization benefit from participating in this course?
Have you attended a nonproliferation/security course before?

YesNo
If your previous answer is "yes" please list a course name and a country
What knowlegde and skills do you expect to receive from this course?
How did you learn about our course?

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Upload and e-mail CV/resume, letter of support/recommendation from your organization to mkalininapohl@middlebury.edu

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Intensive Course "WMD Nonproliferation and Security for Women in STEM" (Rabat, Morocco, March 9-13, 2020)