Principal Investigator:
__________________________
Typed Name
__________________________
__________________________
__________________________
University Mailing Address
__________________________
Signature/Date
__________________________
Office Phone/Home Phone
__________________________
Office EMail
Department Chair:
__________________________
Typed Name
__________________________
__________________________
__________________________
University Mailing Address
__________________________
Signature/Date
__________________________
Office Phone
__________________________
Office EMail
Institution Endorsement and Approval
Institution Official:
__________________________
Typed Name/Official Title
__________________________
__________________________
__________________________
University Mailing Address
__________________________
Signature/Date
__________________________
Office Phone
__________________________
Office EMail
Title of Proposed Research:
Area of Interest of Research:
Algebra______, Number Theory______, Discrete Mathematics______, Probability______,
Statistics_______
Time Period (Date(s) of Conference)
List of Reviewers/Nonreviewers Enclosed: ___Yes ___No
Budget Requested:
Year 1_______ Year 2________
List all organizations, other than NSA that might provide support the conference, along with the requested amounts.
____ONR ____NSF ____AFSOR ____ARMY ____OTHER