Chapman Travel Grant Application - Communicating Climate Science Survey

8-13 June 2013 // Snow Mountain Ranch, USA // Application Deadline: 5 February 2013

Applicant Inforamtion(Required.)

First Name

Middle Name

Last Name

Institution

Institution Address

Mailing Address (if different)

Institution Phone

Home Phone

E-Mail

Age

Gender(Required.)

Female

Male

Country of Birth(Required.)

Other (please specify)

Citizenship(Required.)

Other (please specify)

Are you a student?(Required.)

Yes

No

If yes,

What degree are your working towards?

Expected graduation date

If you are not a student:

Where did you receive your PnD?

When did you receive your PhD?

Title and authors shown on the abstract of the paper you plan to present at this conference.(Required.)

Are you under any contractual or grant support from any government agency?(Required.)

Yes

No

If yes, what is the agency's name?

Can you use these funds for travel to this conference?(Required.)

Yes

No

Have you requested any assistance for this conference from your institution?(Required.)

Yes

No

Estimated Travel-Related Expenses in US Dollars
Oanda Currency Convertre tool - http://www.oanda.com/currency/converter/(Required.)

a) Estimated economic round-trip airfare between residence and destination

b)Estimated lodging, based on room rate + tax posted on website (you are encouraged to share a hotel room)

c)Other expenses (no including conference registration)

Description of other expenses

Total Estimated Travel Expenses (sum of A-C)

Amount of this total being request from AGU

Amount of this total being provided by your institution or other source

Amount of this total being paid by you

I certify that all information contained in this statement is true and correct to the best of my knowledge and belief.(Required.)

Yes

Electronic Signature(Required.)

If you are a student you must complete this section

Faculty Advisor Name

Faculty Advisor Position

Faculty Advisor Phone Number

Faculty Advisor E-Mail

Association with Student

Advisor's brief statement on why they believe it is particularly beneficial for this student to attend this conference.(Required.)

Is the student in good academic standing and actively engaged in research?(Required.)

Yes

No