COSMOS SCHOLARS Program Application Form 2010-2011

COSMOS SCHOLARS Program (Grants to Graduate Students)
2010-2011 Application Form

All applicants must complete this application form and submit online by November 2, 2010.

Please note items marked * are required. Enter N/A if not applicable.

*Prefix: Mr. Miss Ms. Mrs. Other (type alternate title here or N/A)
First Name: M.I. Last Name: Suffix:
*Street Address:
*City:	*State/Region:
*Zip/Postal Code:	*Country:
*Primary Telephone:	Secondary Telephone (if any):
*E-mail:	Fax:
*Institution:
*Department/Program:
*Enrollment Status: Full-time Part-time
*Degree Sought: If Other Master Degree selected, please specify: If Other Doctoral Degree selected, please specify:
*Dissertation/Thesis Title:
*Proposal Title:
*Amount Requested: $ Note: use only numbers (e.g., 1200 or 800.85)
*How will the money be allocated?
*Other support, if any, sought or received for proposal:
Note: No recommendation letter from the academic/faculty advisor is required or expected at the time of the application. However, the following information must be provided; if the application is successful, the academic/faculty advisor will be contacted and required to verify the applicant's academic status and the feasibility of the proposed work at the institution. The applicant should obtain the advisor's consent to this procedure before submitting the application.
*Academic/Faculty Advisor's Name:
*Advisor's Title:
*Institution:
*Department:
*Advisor's Phone Number:	Advisor's Fax Number:
*Advisor's E-mail Address: