1.  Group Name (Full):  _______________________________________________

2.  Acronym (if applicable):  _________________________________________

3.  Group Tax Identification Number (TIN):  ___________________________

4.  Date of group formation:  _________________________________________

5.  Short statement of the goals or purpose of the group:  ____________

    ___________________________________________________________________

6.  Is the group a current recognized GSAS student organization?  Y / N

7.  Is the group connected with a department or administrative unit of

    the University?  Y / N       If yes, which?  ______________________


8.  Contact person:

    Provide this information for the individual who will be available
    to answer questions about this application.  This person must be
    available (or should be able to designate a substitute) to appear
    in person at both a Budget Committee meeting and the GSC meeting
    at which this reimbursement request is considered.  Should a
    representative not be available, the GSC may decide not to act on
    this reimbursement request.

    (a)  Name:  _______________________________________________________

    (b)  Harvard ID#:  ________________________________________________

    (c)  University Address:  _________________________________________

    (d)  Phone:  ______________________________________________________

    (e)  E-mail:  _____________________________________________________

    (f)  Position in group:  __________________________________________


9.  Total amount of funding requested from the GSC:  __________________

10. Has this group received GSC funds previously?   Yes  /  No

    If yes, indicate (for the current and previous academic years):

        Approximate Date     Amount Received     Purpose

    ___________________________________________________________________

    ___________________________________________________________________

    ___________________________________________________________________