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NAME:

HOME ADDRESS:

WORK ADDRESS:
(department,
institution,
street address,
city/state/ZIP)

 

E-MAIL:

 

INSTITUTION TYPE: Public ____ Private ____

2-year College ____ 4-year College ____ University ____

COURSES TAUGHT THIS YEAR--INDICATE U (UNDERGRADUATE) OR G (GRADUATE):

NUMBER OF STUDENTS TAUGHT THIS YEAR:_________

DEGREES YOUR DEPARTMENT GRANTS:_________

HOW MANY YEARS HAVE YOU BEEN TEACHING?__________

CITIZENSHIP (IF NOT U.S., SPECIFY COUNTRY, MONTH AND YEAR U.S. RESIDENCE BEGAN)

TELEPHONES, HOME AND WORK (INCLUDE AT LEAST ONE WHERE A MESSAGE CAN BE LEFT AND INDICATE WHICH):

NAME OF DIRECTOR AND TITLE OF SEMINAR OR INSTITUTE TO WHICH YOU ARE APPLYING:

LIST DATES AND TITLES OF NEH SEMINARS AND INSTITUTES YOU HAVE PARTICIPATED IN:

how did you learn about this seminar or institute?
e-mail___ NEH flyer (posted___or sent to you___) NEH website___ other (specify)__________

______________________________________________________________________________

(printed name)

(signature)

(date)