For User Admin Use Only

 Proposal No.     ____________ 

 Date Received   ____________	
SSRL PROPOSAL FORM

1.  PROPOSAL CLASSIFICATIONS:
	New proposal	OR		Replacement for Proposal No. ________
	Single experiment	OR		Program

2.  SUGGESTED REVIEW PANEL: 
	Solid State & Materials Chemistry/		Solid State Physics &		Structural Molecular Biology & 
	Environmental Science 		Materials Science		Biophysics

3. TITLE:  

4. BRIEF ABSTRACT (Please limit to 300 words/2000 characters):   

5. WILL HUMAN SUBJECTS OR LABORATORY ANIMALS BE USED?		No		Yes, details provided in proposal.

6. POTENTIAL SAFETY CONCERNS OR HAZARDS 
	No hazardous substances, equipment, or procedure will be brought to SSRL as part of this proposed experiment.

If you do NOT check the box above, list below all potential safety hazards including toxic, radioactive, reactive, and flammable materials; biohazards; infectious agents; or hazardous procedures or equipment. Additionally, provide detailed safety procedures in proposal text. 

7. WILL PROPRIETARY RESEARCH BE PERFORMED?	 	No		Yes   

8. SPOKESPERSON and COLLABORATORS:  (list spokesperson first)
Full Name 	Full Institution & Address 	Work Phone	Fax Number	E-mail Address	Degree

9. APPROPRIATE PROPOSAL REVIEWERS:  (Do not include people you have worked or collaborated with during the last five years or SSRL staff members.  Provide complete contact information.) 
Full Name 	Full Institution & Address	Work Phone	Fax Number	E-mail Address

10. INAPPROPRIATE PROPOSAL REVIEWER: (List scientists whom for reasons of conflict of interest should not review this proposal.)	
Name	Institution

11. EXPERIMENTAL STATIONS REQUIRED: 
(If two stations required, list both under first choice.)

First Choice(s)	Alternates	

12. ESTIMATED BEAM TIME REQUIRED IN 8-HOUR SHIFTS, IN SIX-MONTH BLOCKS:
1st  6 months		2nd  6 months		3rd  6 months		4th  6 months		

13. FOR EXPERIMENTS ON UHV BEAM LINES, list all samples you expect to insert into the vacuum system and any 
construction materials and components not generally considered UHV materials or components.  Provide details in proposal. 

14. SSRL EQUIPMENT OR MATERIALS REQUIRED:  

15. HAS A PROPOSAL COVERING THIS RESEARCH been submitted to other synchrotron radiation facilities?  If so, which? Are there particular capabilities of SSRL that are required for portions of this research? 

16. REQUIRED FOR DOE REPORTING PURPOSES: 
RESEARCH AREA (check all that apply)	
 	Materials Science
	 	Polymers 	 	Earth Sciences	 	Instrumentation or Other Development	
 	Physics
	 	Medical Applications 	 	Optics	 	Purchase of Specialty Services or Materials	
 	Chemistry 	 	Biological and Life Sciences	 	Engineering	 	Other: (specify)
	
FUNDING AGENCY (check all that apply)	
	DOE/BES		DVA		NSF		Fdn/Research Inst.	
	DOE/BER		NASA		USDA		State/County/City	
 	DOE Other: (specify)
	 	NIH	 	Other US Gov’t: (specify)	 	Prof/Voluntary Assoc.	
 	DoD: (specify)
	 	NIST	 	Industry	 	Foreign: (specify)
	
 	Other: (specify)	

  This research is deemed to be of interest to the DOE and falls within the scope of the BES mission.  

   Keith O. Hodgson, SSRL Director	  Date: