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Participant Information Form
2009-10

The Division of Mathematical Sciences (DMS) of the National Science Foundation, which funds SAMSI, requires that all DMS-supported institutes collect information about participants in their activities. Please fill out the form and click the "Submit Information" button. Items in Red are required.

The information below will be used by SAMSI and DMS solely for statistical purposes, and will not be shared with other organizations. Participants may also decline to provide certain elements of personal demographic information.

Thank you for your cooperation.


Contact Information

Family Name

First Name

Middle Name or Initials

Suffix (Jr, ...)

E-mail (If you have multiple e-mail addresses, please enter the most permanent one.)

If you have provided this information to SAMSI since July 1, 2009 and if there are no changes, check here and click the "Submit Information" button at the bottom of this page. You need not complete any other items on the form.


Current Academic or Employment Status

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University Participants Only

If you are currently employed or enrolled at an academic institution, please indicate your status.

Undergraduate student

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Academic Information

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Highest Degree

Ph.D. or equivalent

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Bachelors degree or equivalent

Other

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Personal Information

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US Permanent Residence: Check here if you are a permanent resident of the US but not a citizen.

Gender: Female Male Decline to Provide

Race: Check as many as apply. If "Decline to Provide" is checked, it will override any other information.

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Asian

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Submission

 

 

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