Today's Date:

Duration of Visit:

Start Date:

End Date:

First Name:      Last Name:

Title:

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JINA Location you are visiting/working at:

Local Address:

Home Institution Address:

Local Phone:      Home Institution Phone:

Fax:      E-Mail:

(MRC1): Stellar Evolution      (MRC2): Supernovae      (MRC3): Neutron Star Laboratory

Scientific Emphasis:

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Salary / Stipend

Travel Reimbursement

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The following information is used in reporting to NSF - but will remain confidential.

Citizenship:      US Citizen      US Permanent Resident      Visiting only      Country:

Ethnic Group:      African American      Asian      Hispanic     
                        Native American       White, non-Hispanic      Other

Gender:      Male      Female

Status:      faculty      postdoc      visitor      graduate student
                undergraduate      high school student
                teacher      JINA associate      JINA interest group

Disabilities: