American Chemical Society Other Committee of the Board, Chemists with Disabilities

Travel Grant Program

ACS Committee on Chemists with Disabilities

Travel Awards for

Students and Postdoctoral Researchers

Application Form

Please complete this form and return it as part of your application package. You may review the award criteria and application instructions at http://membership.acs.org/C/CWD. If you need further assistance or information, please contact Kathleen Thompson, ACS-CWD staff liaison, at 800 227-5558 ext. 8072, TDD (202) 872-6355, email: cwd@acs.org

Full Name (First MI Last): ___________________

Phone Number (Day): __________

(Evening): __________

Mailing Address: ________________________

_________________________

________________________

E-mail: ________________________

Your social security number: ______________

(This award is considered taxable income.)

Your ACS membership number: __ ____________

Meeting at which you will be presenting :

(Name) _____________________________

(Date) ___________________________

(Location) _______________________ _____

Student Status Undergraduate Years Graduate _ Years Post-Doctoral _ Years

Please list any scientific meetings you have attended in the last 3 years.

________________________________ ______

______________________________________

Please list presentations given at scientific meetings in the past 3 years.

_____________________________________

Please estimate costs associated with meeting attendance.

Standard Costs Additional Costs*

Transportation

Lodging

Food

Registration fees

Other

Please specify _

Total _ + _ = _____

* “Additional Cost” is any transportation or lodging cost that aids a person with a disability more than the able bodied. These costs can range from taxi fare for those for whom public transit is impractical or unsafe to the cost of a personal assistant for a quadriplegic.

What sources of funding are available from your department, research grants, or other means? Please specify sources and amount of funding.

________________________________________

Please provide a brief explanation of the nature of your disability.

________________________________________

SIGNATURE ____________________________________________

Travel Grant Guidelines