BETA BETA BETA
AUTHOR DATA SHEET

This form, must be completed, signed and returned to the convention director before a paper can be presented at any TriBeta meeting. A copy must accompany abstracts sent to the National Office for publication in BIOS.

Author's Name(s)________________________________________________ _______________________________________________________________

Name(s) of supervising faculty______________________________________

Paper title_____________________________________________________ _____________________________________________________

Sponsoring TriBeta chapter_______________________________________

Membership status at time of presentation (choose one for each author):

Author #1: Active____ Assoc.____ Grad.____ Year initiated______

Author #2: Active____ Assoc.____ Grad.____ Year initiated______

Author #3: Active____ Assoc.____ Grad.____ Year initiated______

Institution where work was completed:_____________________________

Is this work part of a larger research program? Yes___ No___

If yes give name of program director._______________________________

If part of a research program, was permission given by program director or supervisor for report of this work? Yes____ No____

Address and phone number at which you can be contacted: _____________________________________________________________

Phone: (_____)__________

email:________________________________

We state that the above information is accurate and truthful. Signature________________________________________ Signature________________________________________ Signature________________________________________