Science & Engineering Faculty Directory Template

Directory Inclusion Form

Name and Address:

Last Name:

First Name:

Department:

Title:

Institution:

Phone:

Mail Address:

E-Mail:

Fax #:

Homepage Url:

Concise Description of Research Interests (Approximately 100 words):

Most Recent/Significant Publications (up to 3):

Special Honors, Awards, and/or Interests:

Ethnicity:
General Ethnicity:
Specific Ethnicity or Tribe (if applicable):

Do you consent to have your photograph included in this on-line directory? Yes No

To include your photo in the on-line directory, please submit either a JPEG or GIF file or
a photograph.

How will you submit your photograph?

I will enclose the picture in an email message.
I will send the photo via postal service to:
I have already submitted a photo.

JJ Jackson
MIT Provost's Office
77 Mass. Ave., Rm 26-161
Cambridge, MA 02139
Voice: 617-253-7261
FAX: 617-258-9176
email: jj@mit.edu

Please download my photo from the Web. The URL is: