<p> ANNEE 2016/2017</p><p>AUTORISATION TO INITIATE THE PROCEDURE FOR DEFENSE Before starting filing the proposal to constitute the jury.</p><p>Enrolment institution (delete as appropriate)</p><p>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] </p><p>Name:...... First name:...... INE :...... Marital name:...... Is running for the preparation of the PhD in the field (see list of titles below): ...... </p><p>Registrated in ……year If International joint supervised PhD, specify the country : ...... </p><p>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...... </p><p>Planned date for the defence : ...... Join the intended composition of the jury</p><p>* 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)</p><p>Name: ...... )</p><p>...... Date, signature</p><p>Co-Supervisor(2) (HDR) Favorable (1) Unfavorable (1)</p><p>Name: ...... )</p><p>...... Date, signature</p><p>Co-supervisor(2) (non HDR) Favorable (1) Unfavorable (1)</p><p>Name: ...... )</p><p>...... Date, signature</p><p>______Head of the laboratory Favorable (1) Unfavorable (1)</p><p>Name: ...... )</p><p>...... Date, signature</p><p>______Director of Doctoral Studies Favorable (1) Unfavorable (1)</p><p>Nom :...... Date, signature</p><p>______Head of the Doctoral School Favorable (1) Unfavorable (1)</p><p>...... Date, signature</p><p>(1) Delete as necessary and motivate the unfavorable opinion (2) If necessary</p><p>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). </p>