If you reproduce this page, the information must appear with the headings listed in the order printed here. Do not exceed the space allotted on this page. Incomplete or inaccurate applications may be deemed ineligible.
NAME:
HOME ADDRESS:
WORK ADDRESS:
(department,
institution,
street address,
city/state/ZIP)
E-MAIL:
INSTITUTION TYPE: Public Private
2-year College 4-year College University
COURSES TAUGHT THIS YEAR--INDICATE U (UNDERGRADUATE) OR G (GRADUATE):
NUMBER OF STUDENTS TAUGHT THIS YEAR:
DEGREES YOUR DEPARTMENT GRANTS:
HOW MANY YEARS HAVE YOU BEEN TEACHING?
CITIZENSHIP (IF NOT U.S., SPECIFY COUNTRY, MONTH AND YEAR U.S. RESIDENCE BEGAN)
TELEPHONES, HOME AND WORK (include at least one where a message can be left
and indicate which):
NAME OF DIRECTOR AND TITLE OF SEMINAR OR INSTITUTE TO WHICH YOU ARE APPLYING:
LIST DATES AND TITLES OF NEH SEMINARS AND INSTITUTES YOU HAVE PARTICIPATED IN:
HOW DID YOU LEARN ABOUT THIS SEMINAR OR INSTITUTE?
NEH WEBSITE___E-MAIL___ NEH FLYER (POSTED___OR SENT TO YOU___) OTHER (SPECIFY)__________
____________________________________________________________________________________
(printed name) (signature) (date)