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Leg(s) number(s): ______________________________________________________________________________ Name (last, first, middle): ______________________________________________________________________ Institution (include street address): _________________________________________________________________ _____________________________________________________________________________________________ Telephone (Work): ______________________ (Home) ____________________ (Fax) ______________________ E-mail address: _______________________________________________________________________________ Present academic status: _______________________________________________________________________ Primary/secondary fields of study: _______________________________________________________________ Country of citizenship: ____________________________________ Passport No. _________________________ Place passport was issued (city and country): ______________________________________________________ Date passport was issued: _____________________________ Date of expiration: _____________________________ Place of birth (city and country): _________________________________________________________________ Date of birth (day/month/year): ___________________________ Gender: __________________________________ Personal and/or academic references (names and addresses): 1) ___________________________________________________________________________________________ ______________________________________________________________________________________________ 2) ___________________________________________________________________________________________ ___________________________________________________________________________________________ 3) ___________________________________________________________________________________________ ___________________________________________________________________________________________ Previous sea-going experience? (Y) ______ (N) ______. If so, what was the nature of this involvement? (e.g., previous cruise participant, shore-based participant, etc.): ______________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Please return this form, via your national ODP office, to:
Ocean Drilling Program Texas A&M University Research Park 1000 Discovery Drive College Station, Texas 77845-9547 U.S.A. Fax: (979) 845-0876 |