Intent to Participate Form

Please print or type requested information and return this form before January 10, 2008

School Contact/

Advisor Name: Title:

E-mail address: Home Phone (optional): ( ) –

School Name:

School Address: Street

City State Zip code

Preferred mailing address if different from school address:

School Phone: ( ) – School Fax: ( ) –

Is the e-mail address written above the best way to reach you with important information? (Check one)

Yes No If no, please suggest an alternative:

If we need to call, what are the best times to reach you?

Which categories does your school intend to enter? (Please indicate the number of entries from each category)

Alternative Energy Sources Medicine/ Healthcare

Environment New Materials

To aid our planning, please indicate the number of students you expect to have on each of your teams:

2 member teams 3 member teams 2 and 3 member teams, (students will be given the choice)

By submitting this form, I am committing my school/students to entering the Chemagination contest.

I will: notify Dr. Korlipara immediately if there is any change in the status of our participation or our entries.

Signature: Date:

Send or fax to:

Dr. Vijaya L. Korlipara, 301 St. Albert Hall, College of Pharmacy & A.H. P., 8000 Utopia Parkway, St. John’s University, Queens, NY 11439 Fax: 718-990-1877

Questions? Call Dr. Vijaya Korlipara at 718-990-5369 or E-mail: korlipav@stjohns.edu