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Kansas State University, Manhattan, Kansas (http://www.math.ksu.edu/pas) Last Name: ________________________________First Name:_______________________________ Social Security Number _____-____-_______ Country of Legal Residence ________________________________ Affiliation: __________________________________________________Grad. Stud. / Post Doc. / Faculty Mailing Address: _____________________________________________________________________ City/State//Zip Code______________________Country_________________________________________ E-mail Address: ________________________________________________________________________________ Telephone:
______________________________________ Fax:
___________________________ Estimated cost for attending the conference: (All funds are in US Dollars) Hotel Cost: _____ days x $_____(per day) Total $_______ Travel Cost: Airfare
$______ Other ___________
$_______ Total Travel Cost $_______ Do you have any other source of support to attend the conference? Yes____ No____ If yes, indicate: Sources (or agencies)__________________________________ Amount $_________________ The amount you are applying for support from the
conference: $_________ I swear that the above information is accurate based on my best knowledge. ______________________________________
_______/_____/______________ Send the form to: Glenda Larkins, Dept of Mathematics, Cardwell Hall 138, Kansas State University, Manhattan, KS 66506, USA, Fax: 785-532-0546. |