Face Page
Epilepsy Research Recognition Award Application
Category: _____ Basic Scientist ______ Clinical Investigator
Candidate Name: ____________________________________________________________________
Candidate Current Affilliation: _________________________________________________________
Postition/Title: _______________________________________________________________________
Deptartment: ________________________________________________________________________
Address: ____________________________________________________________________________
City/State/Zip: ______________________________________________________________________
Phone: _________________________________ Fax: __________________________________
E-mail: _____________________________________________________________________________
Candiate Signature: ________________________________________________