Name of group or institution:
Contact Name:
Title:
Institution:
E-mail:
Phone:
Where the workshop will be held:
Tentative date of workshop: Please enter at least 3 possible dates (Spring 2006, Fall 2007, etc.).
Workshop you would like to have:
Audience you are targeting:	Junior women science faculty Senior women science faculty Postdoctoral Associates and/or graduate students Graduate Students Other, please specify:

Budget plans to cover costs excluding Travel Workshop Award:

Reason for wanting to hold a workshop: