Chapman Conference Travel Grant Application - Scientific Challenges Pertaining to Space Weather Forecasting Including Extremes Survey

1.Applicant Information(Required.)

First Name

Middle Name

Last Name

Institution

Institution Address

Mailing Address (if different)

Institution Phone

Home Phone

E-Mail

Age

2.Gender(Required.)

Female

Male

3.Country of Birth(Required.)

Other (please specify)

4.Citizenship(Required.)

Other (please specify)

5.Are you a student?(Required.)

Yes

No

6.If yes,

What degree are your working towards?

Expected graduation date

7.If you are not a student:

Where did you receive your Ph.D?

When did you receive your Ph.D?

8.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.

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

Yes

No

10.If yes, what is the agency's name?

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

Yes

No

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

Yes

No

13.Are you receiving financial support to attend this conference?

Yes

No

If yes, what amount are you receiving?

14.Estimated Travel-Related Expenses in U.S. Dollars
Oanda Currency Converter 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 (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

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

Yes

16.Electronic Signature(Required.)

17.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

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

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

Yes

No