1. No category

Please print or type. Only one person per form. Form may be copied.
Full Name:___________________________________________________________________________________________________
Preferred Name for Name Tag:___________________________________________________________________________________
Organization:_________________________________________________________________________________________________
Address:____________________________________________________________________________________________________
City:_________________________________________ State:________________________________ Zip:_______________________
Daytime Phone: (_____)_________________________ Email:__________________________________________________________
Office Use Only CEIS: 125682
Customer ID #_____________________ Receipt # _____________________
Please select only one of the three tracts or other options below.
Track 1: Missouri Transect (select one)
q Climate Team
q Plant Team
q Community Team
q Science Education & Outreach Team
q Cyberinfrastructure Team
q Evaluation
q Administration
q Statewide Committee
q External Advisory Board
Please select one or more options if applicable.
q I am one of the 5 faculty team leads.
q Graduate Student (required to submit abstract; if you have questions or concerns please speak to your primary investigator).
q Undergraduate Student (required to submit abstract; if you have questions or concerns please speak to your primary investigator).
q Postdoctoral Fellow (required to submit abstract; if you have questions or concerns please speak to your primary investigator).
MISSOURI Track-2: Plant Imaging Consortium (PIC) (select one)
q Model 1
q Model 4
q Model 2
q Model 3
q Administration
q Campus Champion
q Outreach
Are you part of the Leadership Team?
q Yes
q No
ARKANSAS Track-2: Plant Imaging Consortium (PIC) (select one)
q Model 1
q Model 4
q Model 2
q Model 3
Are you part of the Leadership Team?
Other (select one)
q Non-EPSCoR Faculty
q Non-EPSCoR Graduate Student
q Non-EPSCoR Undergraduate
q Non-EPSCoR Postdoctoral Fellow
q Administration
q Campus Champion
q Outreach
q Yes
q
q
q
q
q No
General Public
Missouri Legislator
Higher Education
Industry/Private-sector
q K-12 Educator
q Other____________________________
What days are you planning on attending the EPSCoR Meeting?
q June 10
q June 11
q June 12 (External Advisory Board and Missouri Transect Leadership ONLY)
Will you be traveling from outside Columbia to attend this conference?
Do you plan to reserve a hotel room?
q Yes
q Yes
q No
q No
Please write your EPSCoR role here (ex. Lab Technician):___________________________________________________________
Please list any dietary restrictions or required auxiliary aids/services.________________________________________________
How to Register:
Mail: EPSCoR, MU Conference Office, 348 Hearnes Center, Columbia, MO 65211
Phone: (573) 882-4038 or toll-free 1 (866) 682-6663
Fax: (573) 882-1953
Register online: muconf.missouri.edu/EPSCoR/