Application Form: International Conference Travel Scholarship

International Materials Institute for New Functionality in Glass
Please Note: For International Conferences being held outside of US only. Scholarship not applicable to International Conferences being held within the US.

Application date: ______

Conference (Title, Date, Place) ______

BASIC INFORMATION:

Student/Postdoc Applicant:

Name: ______Email: ______

Phone: ______, ______Fax: ______

Address: ______

______

University: ______Major: ______

Academic standing: Postdoc/Graduate/Undergraduate (highlight one)? For how many years? __

Major Subject ______

Grade Point Average: ______Graduation date: ______

Country of Citizenship: ______If non-US are you a Permanent Resident _____ (Y/N)

If non-US citizen or Permanent Resident, indicate US Visa Validity Period: ______

Sex: ______(male/female) Social Security Number: ______

Poster/Paper Title:

Please provide the following:

One-page abstract of the paper/poster to be presented.

Letter of recommendation from faculty advisor, confirming the functionality to be discussed by the applicant in his/her presentation:

Letter to be sent by ______(date).

Faculty Advisor: (person recommending the student for research opportunity)

Name: ______Email: ______

Phone: ______, ______Fax: ______

Address: ______

______

Source of funding for the project: ______

Research Area:

Thrust area(s) most closely related to the presentation:

___ Glassy Metamaterials, novel glasses and nanocomposites

___ Functional Coatings

___ Glasses Engineered for Strength

___ Glasses for ionic functionality

___ Glasses for optical functionality

___ Bio-functional Glasses

Please indicate briefly how your work relates to the achieving new functionality in glass:

List previous conferences attended (Title, Date, Place):

List any awards, honors or publications:

Estimated expenses for attending the conference (List separately: airfare (must be on a US carrier), hotel/dormitory, meals, and registration fee, if any):

Federal Reporting Information: (submission is voluntary)

Are you handicapped? _____ (yes/no)

If yes, describe impairment(s): ______

Ethnic Group:

American Indian _____ (yes/no)

Asian _____ (yes/no)

Black (not Hispanic origin) _____ (yes/no)

Caucasian _____ (yes/no)

Hispanic _____ (yes/no)

Pacific Islander _____ (yes/no)

The completed version of this form may be emailed to IMI at or to the Program Coordinator at . The faculty advisor letter of recommendation and university transcripts should be mailed to:
Ellen Liebenow

Lehigh University
International Materials Institute for New Functionality in Glass
Sinclair Laboratory 120
7 Asa Drive
Bethlehem, PA 18015

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Int’l ConfTravel.doc Revised 12/27/2013