Last Name  *

Title  *

Institution  *

Department  *

Institution Address  *

City  *

State  *

Zip Code  *

Email  *

Phone  *

Fax  *

Home Address  *

City  *

State  *

Zip Code  *

Select Career Level  *  Faculty Member/Independent Investigator    Postdoctoral Fellow   Graduate Student   Undergraduate Student   Other 

Are you a member of the Congressional Liaison Committee (CLC)?  *  Yes   No   Not Sure 

Have you attended a CLS/CLC Capitol Hill Day before?  *  Yes   No 

If so, when?

Which Capitol Hill Day(s) are you interested in attending?  * March 28, 2012  September 12, 2012 

Have you ever met with a Member of Congress? If so, Explain.  *

Have you ever communicated with a Member of Congress? If so, explain.  *

What are your career plans?  *

Briefly state your particular interest in participating in this Capitol Hill Day.  *

Would you like to be considered for a Capitol Hill Day Travel Award?  *  Yes   No 

   

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