Visit Request Printable Version

Mail to:
Rosalie Torres-Martinez, Program Assistant
New Mexico Academy of Science
Visiting Scientist Program
New Mexico Highlands University
Las Vegas, NM 87701

(Please complete form as thoroughly and
accurately as possible)

Scientist:____________________________
Date (first choice):____________________________
Alternate Date:____________________________
Time Presentation to be Given:____________________________
Number of Presentations Requested:____________________________
Topic of Lecture/Demonstration Requested:____________________________
________________________________________________________

Teacher's Name:____________________________
School:____________________________
Grade Level:____________________________
Number of Students:____________________________
Street Address:____________________________
________________________________________________________
City:____________________________
Zip:____________________________
Phone:____________________________

Principal's Approval:____________________________
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          For Office Use Only

Request Rec'd______________Voucher/Rept. Sent______________
Notice to VS______________Voucher/Rept. Rec'd______________
Reply from VS______________Teacher Rept. Rec'd______________
Notice to Teacher______________Scientist Rept. Rec'd______________

School Visit Date______________
Yes______________No______________Pending______________