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Academic Department
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Institution
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Mailing Address
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City
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State
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Zip Code
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A value is required.Invalid format.
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Office Phone
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(xxx) xxx-xxxx
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Fax
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Cell Phone
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E-Mail:
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Gender:
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Ethnicity(ies) (Optional)
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American Indian, Alaskan Native, or Hawaiian Native
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Asian or Pacific Islander
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Black / African American
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Latino/a
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White / Caucasian
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Other
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For Planning Purposes, please
provide the following information (mark all that apply):
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I am a:
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CNY-PR AGEP Steering Committee Member
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Graduate Student
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Undergraduate Student
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Special Meal Requirements:
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Vegetarian
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Kosher
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Nut Allergy
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Other
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I am disabled
and would like to be contacted to discuss my special needs
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Lodging:
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Will you require housing?
Yes
No
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Check In Date:
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Check Out Date:
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If you have a roommate preference, please provide his/her
name:
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