Applicant's Name:

Title of Proposal:

Level at Time of Application (e.g., 3rd year doctoral student, etc.):

Present Title (RA/TA, post-doctoral fellow, etc.):

Office Address:

Office Phone:

FAX:

e-mail address:

Major Professor/Advisor's Name:

I. EDUCATION (include Institution, Major, Dates Attended, Degree granted or expected):
Graduate Record:
1.
2.
3.

Undergraduate Record:

1.
2.

II. PROFESSIONAL HISTORY (list positions held, institutions, dates; begin with current position)

III. PUBLICATIONS (list published papers, lectures, short papers, published abstracts, etc. Attach additional sheets if necessary. In the case of multi-authored publications, indicate your contribution.)

IV. PROFESSIONAL AFFILIATIONS OR MEMBERSHIPS (If already a member of SDE/GWIS, please note date of membership initiation)
Check here if you would like to receive more information about national/local membership and involvement in Sigma Delta Epsilon/Graduate Women in Science.

V. RELATIONSHIP TO DEGREE PROGRAM/CAREER DEVELOPMENT (Describe in a maximum of 2 paragraphs how the proposed research relates to your degree program and/or career development. Be sure to note the role this award would play in your degree attainment/career development should it be awarded.))

VI. COLLABORATIVE/MENTORING CAPACITY (Describe in a maximum of 2 paragraphs initiatives you are participating in to promote the careers of scientists, particularly women, within your institution/program/peer group, etc. Note your role in all initiatives. Evidence of such collaborative/mentoring capacity will be given special consideration by the Award Committee.)

VII. PERSONAL FACTORS (Describe in a maximum of 2 paragraphs relevant personal factors, including financial need, that should be considered in evaluating your proposal, e.g., returning to school after raising a family, supporting self and family while in graduate school, etc.)

VIII. OTHER FINANCIAL SUPPORT (List all sources of support for the research proposed in this application, both current and pending. For all sources, list the name of the granting entity, the amount awarded or applied for, and the dates of support. Include all TA/RA-type support, noting which portions fund tuition, living expenses, and/or research costs, if applicable. NO ONE WHO HAS ALREADY SECURED FULL FUNDING FOR THEIR PROJECT WILL BE CONSIDERED FOR THIS AWARD.)

Current Support:

Pending Support:

IX. PROTOCOLS AND PERMITS (Please check the appropriate statement):
( ) Research does not involve either human or animal subjects or field collections.
( ) Copies of human/animal protocol approvals from my home or host institution OR the proper field collection permits are attached.
( ) Application for approval has been made, but has not yet been received. NOTE: copies must be forwarded to the appropriate committee Chair when received.