\documentclass{article}

\title{VVG network: Placement application form}
\author{}
\date{}

\begin{document}

\maketitle

\section{Administrative details}

{\bf Title for request}\\
{\bf Contact details}\\
Name\\
Email\\
Address\\
Phone\\
Fax\\

{\bf Source institution}

\noindent senior researcher's name\\
name of exchangee\\
address\\


\noindent {\bf Host institution}

\noindent senior researchers's name\\
address

\vspace*{12pt}

\noindent {\bf Length of Stay}


\section{Justification}

\noindent {\bf Specific technical aims and objectives of the visit}


\vspace*{12pt}

\noindent {\bf Outline the research programmes, in each lab, that are relevant
to the request.}


\vspace*{12pt}

\noindent {\bf Outline the benefits to each laboratory taking part.}


\vspace*{12pt}

\noindent {\bf Outline the benefit to the wider convergence community}



\section{Costs}

Travel\\
Accomodation\\
Other (justify)\\
Total\\

\noindent Place list any other contributions to the placement if any, including amount and the source of funding.


\end{document}
