Name or Company Name: ___________________________________________________________

Legal status: ______________________________________________________________________

Established since: _________________________________________________________________

Contact person: ___________________________________________________________________

Email(s) and telephone number(s):___________________________________________________

Location: ________________________________________________________________________

Sector: __________________________________________________________________________

Areas of interest: _________________________________________________________________

wishes to : (a) JOIN THE POLYSEMI NETWORK; (b) COLLABORATE WITH THE NETWORK

The POLYSEMi network is a useful tool: (a) DEFINITELY – (b) ONLY POTENTIALLY

Objectives which could be shared: ____________________________________________________

________________________________________________________________________________

Organizational proposals for the network:__________________________________________________

Project proposals for the network : __________________________________________________

________________________________________________________________________________

Comments (if any): ________________________________________________________________________________

________________________________________________________________________________

Contact(s):_______________________________________________________________________