REGISTRATION FORM FOR PARTICIPANTS NOT ELIGIBLE FOR QEM SUPPORT

 

 

QUALITY EDUCATION FOR MINORITIES (QEM) NETWORK

Historically Black Colleges and Universities Undergraduate Program (HBCU-UP) Workshop

The Embassy Suites Hotel New Orleans-Convention Center

315 Julia Street ¥ New Orleans, LA 70130 ¥ 504/525-1993

Thursday – Friday, October 5-6, 2006

 

This workshop is for HBCUs that are eligible to submit a planning or multi-year proposal in the National Science FoundationÕs HBCU-UP FY 2007 Program competition. QEM support for travel and lodging is available for up to two participants from eligible HBCU institutions provided the institutionÕs chief academic officer is one of the two participants. This registration form should be completed by individuals from eligible institutions where the chief academic officer is not available to attend the workshop. Travel and lodging expenses for such individuals must be covered by the institution; however, workshop meals will be provided for all registered participants. Please provide the information below for each institutional representative, up to three.

 

Workshop Participant Number One:

 

NAME __________________________________________

 

TITLE _______________________________ DEPARTMENT _____________________     ______           

 

INSTITUTION ____________________________________

TELEPHONE: ______________________     FAX: __________________________________

 

E-MAIL: _________________________________________

 

 

Workshop Participant Number Two:

 

NAME __________________________________________

 

TITLE _______________________________ DEPARTMENT _____________________     ______           

 

INSTITUTION ____________________________________

TELEPHONE: ______________________     FAX: __________________________________

 

E-MAIL: _________________________________________

 

 

Workshop Participant Number Three:

 

NAME __________________________________________

 

TITLE _______________________________ DEPARTMENT _____________________     ______           

 

INSTITUTION ____________________________________

TELEPHONE: ______________________     FAX: __________________________________

 

E-MAIL: _________________________________________

 

Please e-mail the completed registration form to Shirley McBay at smmcbay1@qem.org by Friday, September 8, or send it by fax to 202/659-5408.