Virginia EMS Conference Scholarship Application



Virginia EMS Conference Scholarship Application

Roanoke, Virginia

October 6-8, 2008

Instructions: If financial assistance is needed to attend the EMS Conference, this form is to be filled out and submitted electronically to bherbert@vt.edu no later than August 15, 2008.

Priority will be given to those from federal, state, and local government, colleges and universities. Maximum assistance will be no greater than 50% of the cost to attend the EMS Conference.

The final decision on scholarship awards will be made by August 18, 2008. If assistance is approved, you will be reimbursed for up to the approved amount after attending the EMS Conference and submitting documentation.

We encourage you to coordinate with other personnel traveling from your organization to keep expenses to a minimum. Thank you for your interest in the EMS Conference.

1) Organization Name_________________ _____________________________________

2) Person Requesting Reimbursement__________________________________________

3) Address_______________________________________________________________

4) Phone______________ Fax_________________ E-mail_________________________

5) Is travel restricted by your employer? ______________________________

If yes, please explain how? ____________________________________________

6) What are other possible funding sources? _____________________________________

7) Are you going to be a Speaker? _________________________________________

8) Please estimate the amount of travel you are requesting. Be as exact as possible.

|ACTIVITY/EXPENDITURE |AMOUNT REQUESTED |

|INTERCITY TRAVEL (Airfare/Car Rental/Mileage, Meals) | |

|Conference Registration (Includes hotel, meals, conference registration gratuity and taxes) | |

|OTHER (Please Describe) ___________________________ | |

| TOTAL | |

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