| Name_________________________________________ Title___________________________________________ | Business Address______________________________________________________________________________ ______________________________________________________________________________ |
Phone(______)_________________________Ext________________ Fax(______)_________________________ |
Email_________________________________________________________________________________________ |
Lodging cost estimate: # of hotel nights_______ times room rate (tax included) of $144.00 = $____________ |
(If you would like to save funds and are willing to share a room, please contact Karen Miller at kmiller3@weber.edu) |
Approximate cost of travel $____________ Method of Travel? air / car / other_______________ |
Please choose one option: |
 | Employer will provide $__________________ towards lodging and/or transportation (do NOT include funding for meals,) so I am requesting an award amount of $_____________ |
| Employer provides NO funds for lodging and/or transportation, so I am requesting an award amount of $_____________________ |
Total number consecutive years of dues paying membership in NAOSMM (include present year) _____ |
Is this your 1st Conference? YES / NO Have you received travel funding in the past? YES / NO |
If you have received travel funding in the past, please list which years you have been funded. |
_________________________________________________________________________________________ |
Are you serving on a Committee? YES / NO If yes, which one and for how long? __________________ |
Are you presenting or helping at the conference? YES / NO Explain.________________________ |
Name of immediate supervisor________________________________________________________________ |
Phone(______)_________________________Ext________________ |
Required to receive consideration for travel funding - please check all boexes |
| I would like to attend the NAOSMM Annual Conference. I have received approval for enough time off (vacation, professional training, etc.) to enable me to be present at the conference for at least three FULL days of the conference. |
| I have attached a paragraph detailing why I want to come to the conference and how I think attendance will benefit me. |
| I agree to provide the Awards Chair with an itemized account of my travel and lodging expense no later than two weeks following the conference. |
Notification of awards funding - please check one box: |
| Email notification of awards amount is fine sufficient. |
| I need a formal letter stating the award amount. |
Name and Institution as you would like them to appear on an award plaque or certificate: |
(PLEASE PRINT)____________________________________________________________________________ |
Signature _______________________________________________ Date__________________________ NAOSMM Member |
Signature _______________________________________________ Date__________________________ Supervisor |