This Application Cover Sheet has been designed to be printed from your Web-browser. If otherwise reproduced, the information must appear with the headings listed in the order printed here. Do not exceed the space allotted on this single page. Incomplete or illegible applications may be deemed ineligible.
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):
TITLE OF SEMINAR OR INSTITUTE TO WHICH YOU ARE APPLYING AND NAME OF DIRECTOR:
LIST DATES AND TITLES OF NEH SEMINARS AND INSTlTUTES YOU HAVE PARTICIPATED IN:
CERTIFICATION (By signing and submitting this application, the applicant is certifying that he/she is not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this transaction by any federal department or agency.)
(printed name) (signature) (date)
NOTE: Federal law provides criminal penalties of up to $10,000 or imprisonment of up to five years, or both, for knowingly providing false information to an agency of the U.S. Government. 18 U.S.C. Section 1001.