First Name:		Last Name:		Affiliation:
Rank:	Chaired Professor Professor Associate Professor Assistant Professor Senior Member of Technical Staff Member of Technical Staff Research Scientist Postdoctoral Associate Graduate Student Undergraduate Student Retired Self-employed Unemployed Other	Email:		Web page:
PhD Status:	Earned Expected None Not sure	PhD year:

My research is currently supported by the US government
(e.g. by an NSF, NSA, DoD, or other federal agency grant). Yes No

Please tell us why you are planning to attend the conference and what you expect to gain from attendance.

Please list a couple of your most significant publications or intellectual products. If you are a student, please describe your progress.

References: Only required for students and postdocs. If you are a student, please list your advisor (including e-mail address) and at least one faculty member familiar with your work. If you are a postdoc, please list your faculty mentor (including e-mail address).

Citizenship Status: US Citizen Permanent resident of the US US National None of the above

I hold a faculty position at a University in the United States: Yes No

Gender: Male Female Do not wish to disclose

Disabled: Yes No Do not wish to disclose

Race: American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Do not wish to disclose

City of Departure:

Estimated Air Fare:

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