2008 Lorentzen Award                SUMMARY FORM                    Page 1 of 1

Name ______________________________________________________
                        last                                first                     middle

Mail address ____________________________________________________
for June to
Sept. 2008 __________________________________________________

e-mail __________________________________________________________
                  current                                       June-Sept. 2007, if different

I have read the application instructions and meet the eligibility criteria:________
                                                                                                                 initial

References (Name, title, affiliation)-List three, as noted in the instructions.

_________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________


                                                                                       Check Current
College __________________________________     Level Sophomore[_] or Junior [_]

Major __________________________________

US Citizen or Permanent Resident (yes/no) _____________

Citizenship, if not U.S. __________________________