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Summer of Applied Geophysical Experience (SAGE)
Core Program June 19 (arrival)--July 10, 2003 (departure)
Sponsored by
The University of California
Institute of Geophysics and Planetary Physics
Los Alamos National Laboratory
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APPLICATION FORM
Name______________________________________ Social Security
No.________________________
Male______________ Female______________ Phone(_____)________________________________
Citizenship___________________ Passport Number_________________________(if
not U.S. citizen)
Mailing Address:
_________________________________________________(university
and department or firm, if appropriate)
Street Address_______________________________________________________
City _______________________________________ Stat____ Zip______________
Email Address________________________________________________________
Major Medical Insurer__________________________________(proof
required--copy of contract or ID card)
University in which enrolled or enrolling and address (if
different from above):
______________________________________________________________________________
Undergrad*__________________Faculty Advisor_______________________________________
(Name,
Phone, Fax, email)
Graduate_______________________________________________________________________
Professional_____________________________________________________________________
Foreign/Other___________________________________________________________________
Name address, and telephone number of spouse or relative
in case of emergency:
Name___________________________________ Phone (______)
_________________________
Address________________________________________________________________________
City _______________________________________ State___ Zip________Country
__________
Note: Fee for SAGE 2003 is $350, payable to SAGE 2003/Code
U96E. $100 is due with Application Form.
Non-refundable after June 1 if application is withdrawn.
Application must be received by Monday, March 31, 2003.
Send to:
SAGE 2003
IGPP, MS-C305
Los Alamos National Laboratory
Los Alamos, NM 87545 USA
(505) 667-0920; Fax (505) 665-3107
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