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Scientist

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Name:
Email:
Phone:
Dept:
I cannot participate in the program at this time.
  I may be available to participate in the following month/year:
Please contact me then.

I wish to participate in the program.
Is there anything you'd like us to know as we consider a partner for you?
Hobbies:
   Aviation Cooking Gardening History Photography Politics
   Reading Theatre/opera Traveling Woodworking
  Other: 
Sporting Activites:
   Biking Fishing Golf Hiking Running Sailing/boating
   Scuba diving Skiing Swimming Tennis
  Other: 
Favorite Travel Destinations:
   Africa Alaska Asia Caribbean Europe Hawaii India
   South America Tropics US East Coast US West Coast
  Other: 
Interests:
  
Other comments or suggestions?