Raj Mittra Travel Grant

Application Form

(To be completed by the applicant.)

1	Name of applicant:
2	Date of Ph.D. awarded:
3	Birth date:
4	Country of citizenship:
5	Title of current position (Postdoctoral Researcher, Lecturer, Assistant Professor, Senior Researcher, etc.) and institutional affiliation:
6	Current, complete business address (including e-mail):
7	Education (list institutions, degrees and years earned, postdoctoral positions held, etc., beginning with the most recent).
8	Honors, scholarships, and/or research awards received:
9	Area(s) of research:
10	List up to seven (but no more) most recently published papers. You may also list your Ph.D. dissertation title, year, and name of advisor:
11	Other relevant experience (industrial experience, sabbaticals, short courses, workshops, or other international conferences attended, etc.):
12	If you do not receive an RMTG award, what estimated percent of the total expenses can your institution support for travel to the meeting?
13	Contingency Statement. Please READ CAREFULLY the following and mark the correct statement with an × :
___	If I am not selected to receive the RMTG award, I will not be able to attend the meeting. In that case, please ask the meeting Technical Program Committee to withdraw my paper.
___	Even if I am not selected to receive the RMTG award, I expect my paper will be presented at the meeting. Please DO NOT ask the Technical Program Committee to withdraw my paper.
14	Checklist (refer to the SELECTION section of the award description above for required items):

The following items are attached to this email message (mark each with an “×") in Microsoft Word or PDF (preferred) format:

a.	___ This electronic application form

b.	___ Letter(s) of reference

c. ___ Copy of paper(s) submitted by the applicant to the APS session(s) of the joint meeting

d.	___ Letter or statement of endorsement from the applicant's home institution

e.	___ Optional candidate CV