<p> Jefferson Science Associates, LLC Managing and Operating the Thomas Jefferson National Accelerator Facility for the U.S. Department of Energy</p><p>Application for 2017-2018 Sabbatical/Research Leave Support Program</p><p>Download and complete this form.</p><p>Part 1. Contact Information and Citizenship. The mailing address and e-mail address you provide below are where you will receive notification of status of your application. Name (First, MI, Last) . </p><p>Mailing Address City, State, Zip , Phone Cell E-mail </p><p>Country of citizenship U.S. (citizen or legal permanent resident) Other (specify) Check if applicable Visa type/Date Visa status expires Alien registration number </p><p>Part 2. Proposal. Attach a written proposal (no more than 3 pages please) that describes the significance of your proposed research at the Jefferson Lab, including the major research tasks anticipated in your proposal. Identify below the name of your proposal and the Jefferson Lab researcher with whom you plan to collaborate. Name of Proposal: </p><p>JLab Collaborator: </p><p>Part 3. Professional References. Provide the names and contact information of three professional references from whom you have requested letters of recommendation to support your proposal. References may be submitted with your application or separately mailed. Title: Reference #1: Name Institution E-mail: </p><p>Title: Reference #2: Name Institution E-mail: </p><p>Title: Reference #3: Name Institution E-mail: </p><p>Part 4. Curriculum Vita. Attach a CV (no more than 2 pages please) referencing no more than 10 publications relevant to your proposed research.</p><p>Part 5. Institutional Approval. Attach your institution’s approval for your sabbatical or research leave.</p><p>Part 6. Where to Send Your Application Package. Your application should be e-mailed to [email protected] with the subject line “JSA Sabbatical Support” no later than COB March 31, 2017. If you cannot submit supporting materials in electronic form, those materials may be mailed, with a copy of this application form to the following address. All supporting materials must be received no later than the announced deadline. Packages that do not include this application form will be considered incomplete. Jefferson Science Associates, LLC c/o SURA 1201 New York Avenue, NW Suite 430 Washington, DC 20005 Attn: Chief Governance Office</p><p>Page 1 of 1 January 2017</p>