Seligman Research Form

Name of Requestor*

Email*

Year of Residency/Fellowship*

Title of Research Project

Name of Mentor 1*

Name of Mentor 2*

Description of Project*

Funds Requested (limit $1500)*

How Funds will be Spent*

Please include descriptions, budgeted amounts, and a timeframe in which each expense can be expected.

Were you awarded previous Seligman awards in the FY?*

Select or enter value

If yes, list title of project, reseach or travel, and date of award.

Will another applicant submit a request for the same award?

If you and another applicant both plan to submit funding requests for a reward you are working on together, please check this box.

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