ANNEE 2016/2017

AUTORISATION TO INITIATE THE PROCEDURE FOR DEFENSE Before starting filing the proposal to constitute the jury.

Enrolment institution (delete as appropriate)

Lille1 Lille2 ULCO Artois UVHC Ecole Centrale IMT Lille Douai Other: … Contact : Christophe VAN BRUSSEL, Coordonnateur ED SMRE – 104 Bureau 106 bis, Bâtiment SN2 - tel : +33 3 20 43 40 62 – mail : [email protected]

Name:...... First name:...... INE :...... Marital name:...... Is running for the preparation of the PhD in the field (see list of titles below): ......

Registrated in ……year If International joint supervised PhD, specify the country : ......

Contact information after defending the thesis (address, phone, mail ...):...... TRAINING PROGRAM: Summary of training followed and issued credits (possibly complete on plain paper): a minimum of 60 credits is required to engage the defence procedure...... SCIENTIFIC PRODUCTION: List of publications and communications on the thesis work (possibly complete on plain paper): at least one oral communication in a conference or one publication in an international journal is necessary to initiate the defence procedure......

Planned date for the defence : ...... Join the intended composition of the jury

* Doctoral Domains: GEPO (Géosciences, Ecologie, Paléontologie, Océanographie), IFB (Ingénierie des Fonctions Biologiques), MMC (Molécules et Matière Condensée), OLPCA (Optique et Lasers, Physico-Chimie, Atmosphère) ______Thesis Supervisor Favorable (1) Unfavorable (1)

Name: ...... )

...... Date, signature

Co-Supervisor(2) (HDR) Favorable (1) Unfavorable (1)

Name: ...... )

...... Date, signature

Co-supervisor(2) (non HDR) Favorable (1) Unfavorable (1)

Name: ...... )

...... Date, signature

______Head of the laboratory Favorable (1) Unfavorable (1)

Name: ...... )

...... Date, signature

______Director of Doctoral Studies Favorable (1) Unfavorable (1)

Nom :...... Date, signature

______Head of the Doctoral School Favorable (1) Unfavorable (1)

...... Date, signature

(1) Delete as necessary and motivate the unfavorable opinion (2) If necessary

Director of Doctoral Studies (DDS): GEPO (Xavier VEKEMANS, Nicolas TRIBOVILLARD, Sébastien MONCHY), IFB (Pascal DHULSTER), MMC (Patrick CORDIER, Jean-François PAUL, Anne PONCHEL, Abdelhak HADJ-SAHRAOUI), OLPCA (Frédéric PAROL, Jean-Paul CORNARD, Majid TAKI).