Exit this survey Chapman Travel Grant Application - Silicic Magma Systems Travel Grant Application Question Title Applicant Information First Name Middle Name Last Name Institution Institution Address Mailing Address (if different) Institution Phone Home Phone E-Mail Age Question Title Gender Female Male Question Title Country of Birth Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovine Bostwana Brazil Brunei Darussalam Bulgaria Burkina Fasco Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Equador Egypt El Salvador Equatoria Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana haiti Honduras Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isreal Italy Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Leichtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Maita Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Monaco Mongolia Morocco Mozambique Myanmar Namibia Nepal Netherlands New Zeland Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Kitts an dNevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Saychelles Sierra Leone Sinapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Sqaziland Sweden Switzerland Syrian Arab Republic Taiwan Taijikistan Thailand Togo Trinidad and Tobago Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United Republic of Tanzanie United States of America Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Yemen Yugoslavia Zambia Zimbabwe Other (please specify) Other (please specify) Question Title Citizenship Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovine Bostwana Brazil Brunei Darussalam Bulgaria Burkina Fasco Burundi Cambodia Cameroon Canada Cape Verde Central African Republic Chad Chile China Colombia Comoros Congo Costa Rica Cote d'lvoire Croatia Cuba Cyprus Czech Republic Democratic People's Republic of Korea Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Equador Egypt El Salvador Equatoria Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana haiti Honduras Hungary Iceland India Indonesia Iran (Islamic Republic of) Iraq Ireland Isreal Italy Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Leichtenstein Lithuania Luxembourg Madagascar Malawi Malaysia Maldives Mali Maita Marshall Islands Mauritania Mauritius Mexico Micronesia (Federated States of) Monaco Mongolia Morocco Mozambique Myanmar Namibia Nepal Netherlands New Zeland Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Republic of Korea Republic of Moldova Romania Russian Federation Rwanda Saint Kitts an dNevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Saychelles Sierra Leone Sinapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Sqaziland Sweden Switzerland Syrian Arab Republic Taiwan Taijikistan Thailand Togo Trinidad and Tobago Tunisia Turkey Turkmenistan Uganda Ukraine United Arab Emirates United Kingdom of Great Britain and Northern Ireland United Republic of Tanzanie United States of America Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Yemen Yugoslavia Zambia Zimbabwe Other (please specify) Other (please specify) Question Title Are you a student? Yes No Question Title If yes, What degree are your working towards? Expected graduation date Question Title If you are not a student: Where did you receive your Ph.D? When did you receive your Ph.D? Question Title Are you submitting an abstract (priority will be given to applicants submitting an abstract)? Yes No If yes, provide the title and authors on the abstracts you are submitting. Question Title Are you under any contractual or grant support from any government agency? Yes No Question Title If yes, what is the agency's name? Question Title Can you use these funds for travel to this conference? Yes No Question Title Have you requested any assistance for this conference from your institution? Yes No Question Title Are you receiving financial support to attend this conference? Yes No If yes, what amount are you receiving? Question Title Estimated Travel-Related Expenses in U.S. DollarsOanda Currency Converter tool - http://www.oanda.com/currency/converter/ 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 (not including conference registration) Description of other expenses Total Estimated Travel Expenses (sum of A-C) Amount of this total being requested from AGU Amount of this total being provided by your institution or other source Amount of this total being paid by you Question Title I certify that all information contained in this statement is true and correct to the best of my knowledge and belief. Yes Question Title Electronic Signature Question Title 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 Question Title Advisor's brief statement on why they believe it is particularly beneficial for this student to attend this conference Question Title Is the student in good academic standing and actively engaged in research? Yes No Done