Institution:

Preferred mailing address:

Alternate mailing address: (May 1-July 10): 

Office phone: home phone: fax:

Your email address (required):

Gender: male      female

Citizenship (select one):
citizenship U.S. Citizen U.S. Permanent Resident Non-U.S. Citizen

U.S. Permanent Resident country of origin:

Non-U.S. Citizen country of citizenship:

Visa/Immigration status:

U.S. Citizens and Permanent Residents: this question is optional, but helpful in assessing efforts to attract a diverse group of participants (select one):
Ethnicity (Optional) African American Asian American Caucasian Native American Hispanic

How did you hear about PCMI? (select one) 
how you heard about PCMI Advisor Faculty member Colleague Poster/literature Internet Advertisement

If advertisement, please specify publication:

Will you be able to attend the entire PCMI program? (July 11-July 31, 2004) Yes  No
If not, please specify dates you can attend:

Financial Information

Financial Support requested from PCMI: (check all that apply)
Travel  Lodging  Meals

Funding provided by applicant’s institution: (check all that apply)
Travel  Lodging  Meals

ACADEMIC INFORMATION

Current Position:
Nontenured Faculty or Postdoctoral Scholar   Tenured Faculty

Date of PhD:
Graduate Institution:

Do you currently have NSF funding or other US Government support?

If yes, describe briefly:

Support from other Government?

If yes, please list agency:

Please name no more than five PhD students you have supervised, or are supervising.

Please give a brief description of your current research interests.

Please list titles of recent preprints and publications (no more than five). You may send the abstract and reference pages from one preprint with this application (optional).

 
CAREFUL ANSWERS TO THE FOLLOWING QUESTIONS WILL INFLUENCE YOUR CHANCES OF ACCEPTANCE.

1) You might like to apply with a group of people. If so, please describe your research project and list collaborators.