Scholarship

Performing the World 2010
Financial Assistance Application
Please fill out a separate form for each person requesting support.
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/ Affiliation
College or University (if you are a student)
In a few sentences, please let us know something about you, your desire to participate in PTW 2010, and your need for financial assistance. Please be specific.
Is a Visa required for you to enter the USA??	Yes No
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:
Date of Birth:
Passport #
For more information please contact Melissa Meyer at mmeyer@eastsideinstitute.org or phone 212-941-8906, ext 304.
Deadline: May 15, 2010

East Side Institute