Application Life Imaging Center

Address:
Albert-Ludwigs University
Life Imaging Center (LIC)
Habsburgerstr. 49
79104 Freiburg im Breisgau

2nd Address :
Schänzlestr. 18
79104 Freiburg im Breisgau

e-mail: lic@imaging.uni-freiburg.de

Notes:
Fields indicated by a red asterisk are required and must be completed in order to proceed.

Page 1 of 6 - Personal Information (Applicant)

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Date (day of registration) Date (day of registration) / MM / DD YYYY
Name (Applicant) Name (Applicant) Title First Last Suffix
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Gender

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Preferred Language

Preferred Language English German
Attention !! Please give us only your work (lab) address, no private address!!
Lab Street Address

LAB ADDRESS::
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Postal / Zip Code

BILLING ADDRESS:
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City

BILLING ADDRESS:
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E-Mail Address

Confirm E-Mail Address

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Phone lab (only numbers without hyphens, parentheses, or empty spaces)
My account USER-ID (i.e mm1123)
If you have no USER ID please sign in XX/1111
Uni-Card Number (account number at your Uni-Card)
If you have no Uni-Card please sign in XX/1111

Application for Uni-Card:

You’ll find information about the UniCard for students and staff members of the University of Freiburg and other UniCard users.

https://www.unicard.uni-freiburg.de
Position

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Position (Other)
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Affiliation

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Affiliation (Other)
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Name of Institution

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Company
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Faculty (University of Freiburg)

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Central Research Institut (University of Freiburg)

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Central Research Institut (Other)
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Clinic (Medical Center - University)

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Institute (Medical Center - University)
Medical Interdisciplinary Centers (Medical Center - University)

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Department (Dental, Oral and Jaw Medicine)

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Department (Heart Center, University of Freiburg)

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Department (Internal Medicine)

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Department (Mental Illnesses)

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Department (Pediatrics and Adolescent Medicine)

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Department (Radiological Diagnostics and Therapy)

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Department (Surgery)

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Institute (Faculty of Medicine)

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Department (Faculty of Mathematics and Physics)

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Institute (Faculty of Chemistry and Pharmacy)

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Institute (Faculty of Biology)

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Department (Faculty of Engineering)

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Department (Faculty of Biology)

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Cluster of Excellence (University of Freiburg)

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Cluster of Excellence University of Freiburg (Other)
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Please indicate your cluster of excellence within Freiburg University.
Name of your Work Group / Group Leader Name of your Work Group / Group Leader Title First Last Suffix
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Application Life Imaging Center

Application Life Imaging Center

Page 1 of 6 - Personal Information (Applicant)

Attention !! Please give us only your work (lab) address, no private address!!