| Institution (*): |  | 
        
          | Department (*): |  | 
        
          | Description: (Optional text you wish to use to
 describe your institution, or any other
 comment. This is not saved to the
 database but might be useful in
 processing the form.)
 |  | 
        
          | Head of the Department: | Title: 
 First Name (*):
 
 Last Name (*):
 
 Head's E-Mail (*): [Note: Department's general e-mail
            has a separate field.]
 
 | 
        
          | Address: (Enter three main lines for the
 address, e.g., faculty/department and
 the street address)
 | 
 
 | 
        
          | City / State (if applicable): | State: | 
        
          | Post Box (if applicable): |  | 
        
          | Postcode: |  | 
        
          | Country (*): |  | 
        
          | Telephone: (include country code,
 e.g. +1 for United States)
 |  | 
        
          | Fax: (include country code,
 e.g. +1 for United States)
 |  | 
        
          | Department E-mail (*): |  | 
        
          | Web: |  | 
        
          | Number of Academic
        Teaching and Research Staff:
 | Full Time: 
            Part Time: | 
        
          | Contact: (Enter your name or the name
 of the person
            responsible for
 maintaining information submitted
 to Education Database.)
 | Name: (*) 
 Contact e-mail (*):
 
 | 
        
          | Internet path for a logo: (to be used in the Education Database
 to identify your organization; max. width
 and height 300 x 100 pixels)
 |  |