University of Tulsa

Application for Nanomaterials Workshop

(July 18 – 26, 2005)

Please type, or print, the following information -- return it to Dr. Winton Cornell, Dept. of Geosciences, The University of Tulsa, 600 South College Ave, Tulsa, OK, 74104. Evaluation of applications will be made June 24. Applicants will be notified immediately by e-mail/mail/phone.

Your name:

Mailing address:

Street Address or P. O. Box

Home phone: ( ) City Zip Code

School name:

School address:

Street Address or P. O. Box

School phone: ( ) City Zip Code

E-mail address:

Do you teach science in a public or private high school? Public: Private:

What degree(s) have you earned and in what field(s)?

How long have you been teaching?

What subjects have you taught?

Do you have a teaching specialty? If yes -- in which subject(s)?

How long have you been teaching these subjects?

______

Please explain why you would like to be selected as a participant in this workshop. In what specific ways would you hope to benefit?

______

______

Please complete the following table concerning the classes you teach or will be teaching. Leave blank any cells that do not apply to you. Use additional sheets if necessary.

Type of Science Class / Classes per Year / Average No. of Students per Class / Total Students per Year

We strongly encourage the participation of faculty that teach historically underrepresented and underserved groups, including females, minorities, individuals with limited English proficiency, the handicapped, migrants, the gifted and talented. Of the grand total of all students you teach each year reported above, please estimate the percentage of students in each of the following categories. There may be overlap between students in the various categories:

Female:Minority:

Limited English:Handicapped:

Migrants:Gifted & Talented:

Because of the limited number of participants in this workshop, your selection may mean that other applicants will be turned down. Please explain any circumstances of which you are aware that would prevent your full participation.

Important: By submitting this application, you agree to notify us immediately if anything should arise that would prevent your full participation.

Housing Application

You may apply for housing only if you are unable to commute. Housing will be provided free of charge to the participants. Please let us know if you need help with housing. Do you wish to apply for housing?

Yes: No:

Thank You!

The University of Tulsa does not discriminate on the basis of personal status or group characteristics including but not limited to the classes protected under federal and state law. Questions regarding this policy may be addressed to the Office of Legal Compliance, (918) 631-2423. For accommodation of disabilities, contact TU's 504 Coordinator, Dr. Jane Corso, (918) 631-2334. To ensure availability of an interpreter, five to seven days notice is needed; 48 hours is recommended for all other accommodations.

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