PLEASE CHECK ONE

DATE SUBMITTED

In-Service

Workshop

Class/Course

Other (specify)

Name of Member

Employer

Address of Member

Name of Event/Activity

Sponsoring Agency

Member?

Yes____

No____

Location

Purpose

Date(s) Attending:

From

through

Total Estimated Costs:  (Original receipts for reimbursement for all expenses will be required.)

Registration/Tuition

$

Books/material fees

$

Other (specify)

$

Total

$

Is any portion of the above expenses being paid by an employer, other grants, scholarships, etc.?

{   }

Yes

{   }

No

If yes, what amount

$_____________

I certify that the above information that has been provided is complete and accurate to the best of my knowledge.  I understand that I must abide by the criteria outlined by the Professional Development Committee guidelines or the grant will become a re-payable loan.

Signature

Do Not Write Below This Line

APPROVED BY:  PROFESSIONAL DEVELOPMENT COMMITTEE

Date Approved:

Amount Approved:

$

Date Denied:

Reason for Denial:

After the activity/event has taken place (or a course has been completed), the member will submit a copy of this form to the Committee along with documentation as per the "Criteria for Reimbursement Request."