2018 Scholarship Application

Performing the World 2018
Financial Assistance Application
Please fill out a separate form for each person requesting support.
Check one:
Have you submitted a proposal to present at PTW 2018?
First/Given Name
Last/Family Name
Street Address
City:
State/Province/Region:
Zip/Postal Code:
Country:
Telephone Numbers (include country and city codes)
Work:
Home:
Mobile:
Fax
Email:
Title and Affiliation
College or University (if you are a student)
Is a Visa required for you to enter the USA??
If you answered "yes," please complete the passport information below:
First Name EXACTLY AS IT APPEARS ON YOUR PASSPORT:
Last Name EXACTLY AS IT APPEARS ON YOUR PASSPORT:
Passport #
Date of Birth:

MonthDayYear
My gender is:
Have you attended an earlier PTW conference?
If yes, have you received financial assistance from PTW?
In a few sentences, please let us know something about you, your desire to participate in PTW 2016, and your need for financial assistance. Please be specific.
For more information please contact Melissa Meyer at ptw@eastsideinstitute.org or phone 212-941-8906.
Deadline: April 19, 2018
Should be Empty:

Performing the World 2018