I. Contact Information

*First Name: *Last Name:

*University:

*Address:

*City, State, ZIP:

*Phone #:

*Email Address:

*Gender: Female Male

*Ethnicity (Please check all that apply):

American Indian or Alaska Native
Asian
Black or African American
Hispanic
White
Other:

II. Education and Department Information

* My field of study is:

My projected graduation date is: January February March April May June July August September October November December 2007 2008 2009 2010 2011

* Please list the courses you have taken in physics and related subjects.

* What is the highest physics degree offered at your University? Associate B.A./B.S. M.A./M.S. Ph.D.

* How many total faculty members are there in your department?
* How many female faculty members are there in your department?

*Is there a Women in Science and Engineering Program or similar group on your campus?
Yes
No

If so, how often do you attend events sponsered by this group?
More than 2 times per semester
1-2 times per semester
Less than once per semester
Never

III. Personal Statement

Have you attended any of the previous conference for undergraduate women in physics at either USC, UMichigan, or Yale?
Yes, I attended the 1st USC conference in January 2006
Yes, I attended the 2nd USC conference in January 2007
Yes, I attended the 3rd USC conference in January 2008
Yes, I attended the UMichigan conference in January 2008
Yes, I attended the Yale conference in January 2008

* Explain, in a paragraph, why you would like to attend this conference and what you expect to get out of it:

IV. Research Presentation (Optional)

Participants have the opportunity to give a 10-15 minute oral presentation of research or present research in a poster session. Presenting research is optional and is not a factor for acceptance as a participant. Participants who present will be given guidelines for preparing their oral and poster presentations.

Would you like to present research that you have done as an undergraduate?
I would like to bring a poster to present.
I would like to make an oral presentation.

If you would like to present, please summarize your research topic:

V. Undergraduate Advisor

*Undergraduate Advisor:

*Email Address:

VI. Estimated Travel Expenses

Method of travel:
Airplane
Bus
Car
Train
Other:

Estimated Ticket Cost: (if you will come by plane, bus or train)

My department is willing to contribute this much toward travel and hotel costs (hotel is $60 per person per night):
Please give exact ticket values if you have them. Good estimates for airfare can be obtained by going to an online travel service such as Orbitz or Travelocity.

Distance: (for those driving)

VII. Accomodation Information

I would like accomodations for the following nights:
Friday
Saturday

If you know someone else who is coming, with whom you would like to share a room, please enter her name:

Meals will be provided from breakfast on Saturday through an afternoon snack on Sunday. Do you have any dietary restrictions?

VIII. Notes