GS Application for Graduate Student Travel Award

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Travel Award Form

Student Information

Student Name*

First Name

Last Name

Student Email*

Program*

PhD MD/PhD

Presenting a Poster or Short Talk?*

Presenting a Poster Short Talk Course (Must speak with Osei Tutu)

Is this application for Special Merit Award*

Yes No

From Date

To Date

Location

Address Line 1

Address Line 2

City

State/Province

ZIP / Postal

Country

For a Meeting

Title of Presentation:

Nature of Presentation:

Poster Short Talk Other

Please attach an abstract*

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Please attach a brief statement

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co-signed by you and your Thesis Advisor explaining how this course will contribute to your Program of Study

For a Course

Name of Course

Please attach a course description

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Attach only one file

Please attach a brief statement

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co-signed by you and your Thesis Advisor explaining how this course will contribute to your Program of Study

Anticipated Cost of this Trip

Amount anticipated from other sources

Registration

Transportation

Accommodations

Miscellaneous

Total

Please Note:

Each student is eligible for Travel Award consideration once per academic year. Awards range from $200 to a maximum of $600. There are four deadlines for Application Submissions. Consult the student-Faculty Handbook for complete details.

Please submit any supportive comments that you think will assist the Committee in its decision.

Amount anticipated from other sources

Student Agreement

I understand that if I begin a Scholarly Year program without having obtained prior written approval that my status can automatically be converted to an administrative leave.

I have read, understand and agree to the terms of this Scholarly Year

Signature*

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Thesis Advisor Name

First Name

Last Name

Thesis Advisor Email*

MTA Co-Director Name*

First Name

Last Name

MTA Co-Director Email*

Thesis Advisor Approval

Thesis Advisor Approval*

Approve Disapprove

Signature

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MTA Co-Director Approval

MTA Co-Director Approval*

Approve Disapprove

Signature

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For Office Use Only

Recommendation of the Travel Award Committee/Dean:

Approve Disapprove

Amount* $