Faculty Application Form
Faculty Name

Title and Department

Name of Institution


Address


City

Zip Code
Telephone Number
FAX Number

E-mail

Protégé's Name
(if known)
Please submit a résumé/curriculum vitae in electronic format (HTML or MS Word).
Also include a brief summary of experience in similar projects or history of serving
minority students.

I certify these fundswill be used for mentoring underrepresented minority students
(as defined by MGE@MSA):

YES
 

PROJECT FUNDING

PLEASE CHECK ALL THAT APPLY:
Faculty Mentoring Institute
(Participants may or may not be currently mentoring a minority Ph.D. student.
Budget of $500 awarded to all faculty participants at the conclusion of training
workshops held at each institution.)

Materials /Supplies

Software




Faculty Travel

Duplicating

Student Travel
  TOTAL
  (Maximum $500)
  TOTAL
  (Administrative Fee* to institution for accounting & related overhead costs @ 26%)

 

Faculty Mentoring/Documentation of Student Research
Materials /Supplies

Software




Faculty Travel

Duplicating

Student Travel
  TOTAL
  (Maximum $500 per Protégé per semester $350 per quarter)
  TOTAL
  (Administrative Fee* to institution for accounting & related overhead costs @ 26%)


Faculty Mentors' Communication Network

Participant:
Materials /Supplies

Software


Faculty Travel

Duplicating


Student Travel
  TOTAL
  (Maximum $500 per Protégé per semester $350
per quarter)
  TOTAL
(Administrative Fee* to institution for accounting & related overhead costs @26%)
Faculty Facilitator:

Materials /Supplies

Software




Faculty Travel

Duplicating

Student Travel
  TOTAL
(Maximum $2,500 per semester or $1,750
per quarter)
    TOTAL
    (Administrative Fee* to institution for accounting & related
overhead costs @ 26%,excluding consultant stipend, if any,)
Faculty Mentor/Protégé Pairing Service
  Faculty Mentor's major field and area(s) of specialization:

*An Administrative Fee is NOT APPLICABLE for projects conducted at
Arizona State University.

 

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Voice: (800) 327 - 4893 (Students) • (480) 965 - 3958 (Others)
Fax: (480) 965 - 8309 • E - mail: MGE@asu.edu

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