Thank you for taking the time to complete this form. It is required to process your student's conference support application and, if applicable, to submit your request for support to participate and attend a leading technical conference. Support will be limited to $1,000 per applicant. Full Name: Title: College, University or other Institution: Mailing Address Line1: Mailing Address Line2: City: State: Zip: Phone Number: Fax Number: E-mail Address: __________________________________________________________________ STUDENT INFORMATION (SPACE PROVIDED FOR UP TO THREE STUDENTS): Name of Student who Submitted an Application to this Program: Degree Being Pursued by Student AA BA BS MA MS MBA Ph.D. Anticipated Graduation Date of Student: January February March April May June July August September October November December 2000 2001 2002 2003 2004 2005 Is the student enrolled full-time?: Yes No Student's post-graduation plans:   Name of Student 2: Degree Being Pursued by Student: AA BA BS MA MS MBA Ph.D. Anticipated Graduation Date of Student: January February March April May June July August September October November December 2000 2001 2002 2003 2004 2005 Is the student enrolled full-time?: Yes No Student's post-graduation plans:   Name of Student 3: Degree Being Pursued by Student: AA BA BS MA MS MBA Ph.D. Anticipated Graduation Date of Student: January February March April May June July August September October November December 2000 2001 2002 2003 2004 2005 Is the student enrolled full-time?: Yes No Student's post-graduation plans: _________________________________________________________________ CONFERENCE INFORMATION: Conference Name: Please verify that you do plan to attend this conference Yes No Are you willing, at the conference, to provide your student(s) with guidance and introduce her/him to key people? Yes No Briefly describe why it would be beneficial for your student to attend the designated conference: __________________________________________________________________ EXPENSE INFORMATION: Conference Registration Fee: Indicate schedule of fees, e.g., preregistration fee and registration fee on site Registration Information: e.g., registration contact person, address to which registration information and fee should be sent Air Travel: In addition to estimated cost, indicate airports of departure and arrival, airline and flight information on which quote was based Local Travel: e.g., cost of shuttles to and from airport Hotel: Indicate the duration of hotel stay, the quoted cost per night, and hotel that quoted the rates—including contact information Meals: Do not include meals supplied by the conference