GROUP NUMBER (Circle one):       1      2      3      4      5      6      

PRIMARY INTEREST (Specialty): ________________________________

SECONDARY INTEREST: ____________________________________

MEMBERS (Last name, first name) (Up to 4 persons; 3 recommended):

(1) _________________________________________ (Group Leader)

(2) _________________________________________

(3) _________________________________________

(4) _________________________________________

PROJECT TOPIC:

__________________________________________________________________

ALTERNATE TOPIC:

________________________________________________________________

DATE: __________________________________