molab access service application form

Proposal n°____________
to be completed by LC2RMF
AGLAE ACCESS - APPLICATION FORM
To be sent to [email protected] and [email protected] (by e-mail)
and to Claire Pacheco
Palais du Louvre 14, Quai François Mitterrand 75001 Paris, FR (hardcopy)
1)
Project Title /Titre du projet
____________________________________________________________________________________
____________________________________________________________________________________
2) Acronym (max 20 characters) ______________________________
3) Group Leader (All correspondence concerning this proposal will be sent to the Group Leader)
Family Name
Nationality
First Name
Birth year
Gender (tick the appropriated item):
 female
 male
Home Institution
Legal Status of Home Institution Code1
Home Institution Country Code2
Function / Job / Title
Position Code3
Mailing Address
Phone (office)
Phone (cell)
Fax
E-mail
5)
Total requested beam time /Nombre de jours demandés
1
UNI=University, RES=Public Research Organisation, SME=Small or Medium Enterprise, PRV=Other and/or profit or not
profit Private Organisation, OTH= Other Organisation
2
AL=Albania, AT=Austria, BE=Belgium, BG=Bulgaria, CH=Switzerland, CY=Cyprus, CZ=Czech Republic, DK=Denmark,
EE=Estonia, FI=Finland, FR=France, DE=Germany, GR=Greece, HR=Croatia, HU=Hungary, IS=Iceland, IE=Ireland,
IL=Israel, IT=Italy, LV=Latvia, LI=Liechtenstein, LT=Lithuania, LU=Luxembourg, MT=Malta, MK=Macedonia,
ME=Montenegro NL=Netherlands, NO=Norway, PL=Poland, PT=Portugal, RO=Romania, SK=Slovakia, SI=Slovenia,
ES=Spain, SE=Sweden, SR=Serbia, TR=Turkey, GB=United Kingdom
3
UND=Undergraduate, PGR=Post graduate (student with a first University degree or equivalent), PDOC=Post-doc researcher,
TEC=Technician, EXP=Experienced researcher (professional researcher).
AGLAE Access Application Form
1
Specify the requested beamtime, number of days, and preferred periods
Total requested
beamtime (days)
Days of stay
Nombre de jours
Preferred month
Mois préféré
Undesired month
Mois à éviter
4 - Project User Group (please, fill-in all the cells following the example written in blue)
Family Name
First Name
Gender
M/F
Birth
year
Nationality
Ross
XX
F
1979
Belgium
Home Institution(HI)
University, Institute of xxxx
xxxxxxx
Family Name
First Name
First Name
First Name
Home Institution(HI)
IT
Gender
M/F
First Name
HI Legal
State (1)
(2)
Birth
year
HI Country
Gender
M/F
(2)
Birth
year
HI Country
Gender
M/F
(2)
Birth
year
HI Country
Gender
M/F
HI Legal
State (1)
Home Institution(HI)
Family Name
UNI
HI Legal
State (1)
Home Institution(HI)
Family Name
HI Country
HI Legal
State (1)
Home Institution(HI)
Family Name
HI Legal
State (1)
(2)
Birth
year
HI Country
(2)
Background
(chemist,
curator,…)
Architect
Position
Code (3)
e-mail address
PDOC
……@……..
Nationality
Position
Code (3)
e-mail address
Nationality
Position
Code (3)
Background
(chemist,
curator,…)
e-mail address
Nationality
Position
Code (3)
Background
(chemist,
curator,…)
e-mail address
Nationality
Position
Code (3)
Background
(chemist,
curator,…)
Background
(chemist,
curator,…)
e-mail address
Function /Job/Title
PhD
T&S in charge of
CHARISMA
(Yes/No)
Yes
Function /Job/Title
T&S in charge of
CHARISMA
(Yes/No)
Function /Job/Title
T&S in charge of
CHARISMA
(Yes/No)
Function /Job/Title
T&S in charge of
CHARISMA
(Yes/No)
Function /Job/Title
T&S in charge of
CHARISMA
(Yes/No)
Please add as many users as necessary, via copied extra pages
AGLAE Access Application Form
2
6)
AGLAE Local Contact (if any) / Nom du correspondant AGLAE
_____________________________________________________
7)
Beam characteristics / Caractéristiques de faisceau
Particle/Particule
 Proton
 Alpha
 Other
Energy/Energie
Intensity/Intensité
Size/Taille
8)
Method(s) implemented / Méthode(s) utilisée(s)
 PIXE
9)
 PIGE
 RBS
 NRA
 ERDA
 IBIL
Experimental set-up / Dispositif experimental
Detectors/
Détecteurs
Filter
 Low energy X
 High energy X
(4 detectors)
 Charged particles
(external/annular)
 Gamma
Diaphragm
10) Target description / Description des cibles
Number/Nombre
_____________________________________________________
Type
_____________________________________________________
Size /Taille
_____________________________________________________
11) Requested preparation /Demande particulière de préparation
__________________________________________________________________________________
__________________________________________________________________________________
12) Possible risks / risques éventuels
__________________________________________________________________________________
__________________________________________________________________________________
AGLAE Access Application Form
3
13) Project description (Scientific background - Experimental methods - Results expected – References)
Description du project (Contexte scientifique - Méthodes expérimentales - Résultats attendus –
Bibliographie) max. 3 pages
14) Main scientific field of the project (Chemistry, Physics, Material Science, Environment, Humanities,
Social sciences, Engineering and Technology, Inf. Comm. Technology, Others)
__________________________________________________________________________________
15) Specific discipline (specify among the above fields; ex.: field Chemistry- discipline Conservation; field
Environment-discipline Environmental effects on art materials…)
__________________________________________________________________________________
I accept that all the necessary actions regarding the safe transportation of samples/objects back and forth
to the facility, insurance of the samples/objects, etc. are the responsibility of the users, and no associated
costs can be refund within the project.
Date ………………………….
Group Leader Signature
…………..…………………………………………..
AGLAE Access Application Form
4