Application Form

Career Workshop on Minorities and Applied Mathematics

April 22-24, 2005

Participation in IMA programs is by invitation. To request an invitation to an IMA workshop or other program, complete this form and press the submit button at the bottom of the form. Fields labeled in red are required.

Please note:

Online registration is available until about one week before the start of a workshop.
There is no registration fee for IMA programs.
Housing requests and modifications need to be made 10 business days prior to arrival date.

REGISTRANT INFORMATION

Full Name:  
Position: university faculty  postdoctoral researcher graduate student
              industrial scientist government scientist
              other (explain) 

Organization: 
Department: 
Full address (including postal or zip code and country):
   
E-mail:  
Phone: 
Fax:  

Highest educational degree: 
Field:   Year awarded:   
Institution awarding that degree: 

Gender:   Female     Male     Do not wish to provide

Race/Ethnic:   White     Black     Asian/Pacific Islander     American Indian/Native American
                          Hispanic     Other     Do not wish to provide

Citizenship(for visa purposes):   

Referred by:

SUPPORTING INFORMATION

Please explain below your background and interest in the program and send a current curriculum vitae to minorities@ima.umn.edu. A statement of support from an advisor, mentor, department chair, supervisor, etc. is optional; any such supporting material should be sent to minorities@ima.umn.edu.
If you've already been invited to participate in the workshop, just write "invited" below.

POSTER

I would like to present a poster.

Poster title

Poster abstract

REQUESTED PERIOD OF STAY

Arrival Date: Departure Date:

DINNERS

There will be working dinners Friday and Saturday nights. Please indicate your choice of entree for Friday night's dinner below:
Chicken Beef Vegetarian

Saturday night's dinner will be a buffet.

REQUESTED FUNDING

Some limited funding may be available.

Please indicate the type of support you are requesting (if applicable):

Local Expenses (hotel, meals, taxi, etc.)
Domestic Airfare and/or Ground Transportation
Not Requesting Support

Please read about our reimbursement policies.

Thank you for your interest in IMA Programs.

The University of Minnesota is an equal opportunity educator and employer.

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