Individual/Group Leader Grant Application 2013-2014

PERSONAL INFORMATION: NAME STUDENT ID GPA EMAIL TELEPHONE TITLE OF PROJECT AMOUNT REQUESTED YEAR OF GRADUATION MAJOR(S)

RECOMMENDING PROFESSOR (if applicable)

(Optional) If there is a specific grant program that you would like to be considered for, please list it here. You may list more than one.

Have you ever been found guilty of violating the Code of Academic Conduct? Y N (Select one If yes, please include a page with an explanation.) Have you ever been placed on disciplinary probation? (Select one If yes, please include a page with an explanation.) Y N

Are you applying as a group leader? (Deans Grants or Liberal Arts Awards only select one Y N If yes, please attach a list of group members names and email addresses.) If your project is connected to a class (required for Lurcy Grants), please list the course number, title, professor, and semester here. Are you a Louisiana resident? (Required for Putnam grants select one) PLEASE SPECIFY (check one box, and write in the dollar amount): $ ______________ to be paid to applicant via check (W-9 and receipts required) $ ______________ to be transferred into recommending professors account # + Departmental contact name for funds transfer:

How did you learn about our programs? Office use only Review: DG LA Lurcy Henkin Sykes Corasaniti Gordon Devlin Taylor Putnam

Award amount:

Grant awarded:

Account: