Title Select title Professor Dr Mrs Ms Miss Mr Other     If other title

Family name

Personal names

Telephone

Email

Street - line 1

Street - line 2

Street - line 3

City

State

Postcode

Country

Institution/University

Department

City

Country

Funding support from your own university   Yes   No

Discipline

Name of supervisor

Name of referee

Title of presentation

Abstract

To be NO MORE than 300 words

On-campus accommodation in Canberra required for:

• JSGSS (Jan 28 - 31)   Yes   No
• Workshop (Jan 27)   Yes   No
• Master class (Jan 27)   Yes   No

Travel status   Overseas   Australia domestic

Dietary requirements
(if applicable)