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* Title:	DR. MISS MR. MRS. MS.
* Legal First Name:		No Initials
* Legal Middle Name:		Full Name or N/A
* Legal Last Name:		Family Name
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* Email Address:		Provide your business or university email.
* Company/University Name:		Give complete company/university name (define acronyms). This is NOT an email address.
* I work/study in the US	YesNo
* Street Address:		(NO POST OFFICE BOX or EMAIL ADDRESS) Employees provide business address; students provide home or university address
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* Country of Location:	AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHRAIN BALKANS, THE BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BOLIVIA BOSNIA-HERZEGOVINA BOTSWANA BRAZIL BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS COSTA RICA COTE D'IVOIRE, REPUBLIC OF CROATIA CUBA CYPRUS CZECH REPUBLIC DEMOCRATIC REPUBLIC OF THE CONGO DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ESWATINI ETHIOPIA FINLAND FRANCE GABON GAMBIA, THE GEORGIA GERMANY GHANA GREECE GUATEMALA GUINEA GUINEA-BISSAU HAITI HONDURAS HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALI MALTA MARSHALL ISLANDS MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MOROCCO MOZAMBIQUE MYANMAR NEPAL NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN OTHER PAKISTAN PALAU PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR ROMANIA RUSSIAN FEDERATION RWANDA SAINT LUCIA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOMALIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA ST. VINCENT AND GRENADINES SUDAN SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND THE NETHERLANDS TOGO TRINIDAD&TOBAGO TUNISIA TURKEY TURKMENISTAN UGANDA UKRAINE UNITED ARAB EMIRATES UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM WALES YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE	Select "OTHER" if not listed
Other Country		Enter the country name not listed
* Citizenship:	AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHRAIN BALKANS, THE BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BOLIVIA BOSNIA-HERZEGOVINA BOTSWANA BRAZIL BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS COSTA RICA COTE D'IVOIRE, REPUBLIC OF CROATIA CUBA CYPRUS CZECH REPUBLIC DEMOCRATIC REPUBLIC OF THE CONGO DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ESWATINI ETHIOPIA FINLAND FRANCE GABON GAMBIA, THE GEORGIA GERMANY GHANA GREECE GUATEMALA GUINEA GUINEA-BISSAU HAITI HONDURAS HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALI MALTA MARSHALL ISLANDS MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MOROCCO MOZAMBIQUE MYANMAR NEPAL NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN OTHER PAKISTAN PALAU PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR ROMANIA RUSSIAN FEDERATION RWANDA SAINT LUCIA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOMALIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA ST. VINCENT AND GRENADINES SUDAN SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND THE NETHERLANDS TOGO TRINIDAD&TOBAGO TUNISIA TURKEY TURKMENISTAN UGANDA UKRAINE UNITED ARAB EMIRATES UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM WALES YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE	Select "OTHER" if not listed
Other Country		Enter the country name not listed
* Dual/Multiple Citizenship:	Citizen of only 1 country
	Citizen of more than 1 country
Additional Citizenships	AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHRAIN BALKANS, THE BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BOLIVIA BOSNIA-HERZEGOVINA BOTSWANA BRAZIL BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS COSTA RICA COTE D'IVOIRE, REPUBLIC OF CROATIA CUBA CYPRUS CZECH REPUBLIC DEMOCRATIC REPUBLIC OF THE CONGO DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ESWATINI ETHIOPIA FINLAND FRANCE GABON GAMBIA, THE GEORGIA GERMANY GHANA GREECE GUATEMALA GUINEA GUINEA-BISSAU HAITI HONDURAS HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALI MALTA MARSHALL ISLANDS MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MOROCCO MOZAMBIQUE MYANMAR NEPAL NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN OTHER PAKISTAN PALAU PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR ROMANIA RUSSIAN FEDERATION RWANDA SAINT LUCIA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOMALIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA ST. VINCENT AND GRENADINES SUDAN SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND THE NETHERLANDS TOGO TRINIDAD&TOBAGO TUNISIA TURKEY TURKMENISTAN UGANDA UKRAINE UNITED ARAB EMIRATES UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM WALES YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE Add Country Clear Country List Other Country Name Enter the Other Country	Select a country from the drop down list then click Add Country. Click Clear Country List to erase the list and start over if necessary.
* Permanent Residency:	AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANTIGUA AND BARBUDA ARGENTINA ARMENIA AUSTRALIA AUSTRIA AZERBAIJAN BAHRAIN BALKANS, THE BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BOLIVIA BOSNIA-HERZEGOVINA BOTSWANA BRAZIL BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA COLOMBIA COMOROS COSTA RICA COTE D'IVOIRE, REPUBLIC OF CROATIA CUBA CYPRUS CZECH REPUBLIC DEMOCRATIC REPUBLIC OF THE CONGO DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL GUINEA ERITREA ESTONIA ESWATINI ETHIOPIA FINLAND FRANCE GABON GAMBIA, THE GEORGIA GERMANY GHANA GREECE GUATEMALA GUINEA GUINEA-BISSAU HAITI HONDURAS HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALI MALTA MARSHALL ISLANDS MAURITANIA MAURITIUS MEXICO MICRONESIA MOLDOVA MONACO MONGOLIA MONTENEGRO MOROCCO MOZAMBIQUE MYANMAR NEPAL NEW ZEALAND NICARAGUA NIGER NIGERIA NORTH KOREA NORTHERN IRELAND NORWAY OMAN OTHER PAKISTAN PALAU PANAMA PARAGUAY PERU PHILIPPINES POLAND PORTUGAL PUERTO RICO QATAR ROMANIA RUSSIAN FEDERATION RWANDA SAINT LUCIA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOMALIA SOUTH AFRICA SOUTH KOREA SPAIN SRI LANKA ST. VINCENT AND GRENADINES SUDAN SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND THE NETHERLANDS TOGO TRINIDAD&TOBAGO TUNISIA TURKEY TURKMENISTAN UGANDA UKRAINE UNITED ARAB EMIRATES UNITED STATES URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM WALES YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE	Select "OTHER" if not listed
Residency Other Country		Enter the country name not listed
* Phone Number
Fax Number
Website URL
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* Organization Type	Architect-Engineering Consultant Government Contractor Government Laboratory Health Care Industrial Laboratory Industrial Vendor International Center Other Regulatory Agency University Utility
* Project Type	Accelerators Activation/Heating Breeder/LM Criticality Safety Fuel Cycle/Processing Fusion - Hybrid Fusion - Inertial Fusion - Mag. Gas Cooled Reactor Health Physics Res. Heavy Water Reactor High Level Waste Mgt. Light Water R. Low Level Waste Not Available Nuclear Medicine Occup./Envirn. Exposure Other Radiation Dam. Reactor Safety Remedial Action Shipping Casks Space Shielding/Nuc. Systems Weapons Well Logging
* Funding Source(s)
Customers located in the U.S. indicate your source of financial support. If more than one sponsor, indicate percentage of time spent on each (limit to 3 sources). If you have U.S. Department of Energy sponsors, indicate the name of your contact at DOE-HQ in Washington.
Customers located outside the U.S. select Foreign 100%.
Pick funding source(s) from the selections below. Funding Percentage(s) MUST total 100%.
Funding Source 1	CANDU Owners Group Center for Disease Control Defense Threat Reduction Agency Department of Homeland Security DOD - Air Force DOD - Army DOD - Intelligence DOD - Navy DOD - Other (Defense) DOE - Environmental Management DOE - Fusion Energy DOE - Nuclear Energy DOE - Office of Science DOE - Other DOE - Waste Management DOE Nuclear Criticality Safety Program DOE Packaging Certification Program Electric Power Research Institute Environmental Protection Agency Foreign Hospital National Aeronautics and Space Administration National Cancer Institute National Institute of Health National Institute Standards & Technology National Science Foundation NNSA - Defense Programs NNSA - Naval Reactors NNSA - Nonproliferation NNSA - Nuclear Security NNSA - Other Nuclear Regulatory Commission Other Organization Research Institute of Science & Technology (Japan) US University US University Hospital Utility Westinghouse Funding Percentage: DOE Program Manager:
Funding Source 2	CANDU Owners Group Center for Disease Control Defense Threat Reduction Agency Department of Homeland Security DOD - Air Force DOD - Army DOD - Intelligence DOD - Navy DOD - Other (Defense) DOE - Environmental Management DOE - Fusion Energy DOE - Nuclear Energy DOE - Office of Science DOE - Other DOE - Waste Management DOE Nuclear Criticality Safety Program DOE Packaging Certification Program Electric Power Research Institute Environmental Protection Agency Foreign Hospital National Aeronautics and Space Administration National Cancer Institute National Institute of Health National Institute Standards & Technology National Science Foundation NNSA - Defense Programs NNSA - Naval Reactors NNSA - Nonproliferation NNSA - Nuclear Security NNSA - Other Nuclear Regulatory Commission Other Organization Research Institute of Science & Technology (Japan) US University US University Hospital Utility Westinghouse Funding Percentage: DOE Program Manager:
Funding Source 3	CANDU Owners Group Center for Disease Control Defense Threat Reduction Agency Department of Homeland Security DOD - Air Force DOD - Army DOD - Intelligence DOD - Navy DOD - Other (Defense) DOE - Environmental Management DOE - Fusion Energy DOE - Nuclear Energy DOE - Office of Science DOE - Other DOE - Waste Management DOE Nuclear Criticality Safety Program DOE Packaging Certification Program Electric Power Research Institute Environmental Protection Agency Foreign Hospital National Aeronautics and Space Administration National Cancer Institute National Institute of Health National Institute Standards & Technology National Science Foundation NNSA - Defense Programs NNSA - Naval Reactors NNSA - Nonproliferation NNSA - Nuclear Security NNSA - Other Nuclear Regulatory Commission Other Organization Research Institute of Science & Technology (Japan) US University US University Hospital Utility Westinghouse Funding Percentage: DOE Program Manager:
	Funding Percentage Total
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