Professional Development Course/Certification Award Application Form

Date*
MM slash DD slash YYYY
Full Name*
First Last
UH Email Address*
Office Extension Number or Cell Number*
Position at UHMC*
Bargaining Unit Number
Number of Years at this Position*
Name of Course/Certification Program*
Beginning Date of Course/Certification Program*
Location of Activity*
Briefly describe the course/certification program and the impact that it will have on you, your department, UHMC students and UHMC.*
Limit description to approximately 200 words or less.
List all estimated costs with description of the cost.*
Estimated Costs - Note: This fund does not reimburse for lodging, if you receive per diem from another source. This fund does not reimburse for food costs nor offer per diem.
Enter the dollar amount you are requesting from the UHMC Staff Professional Development Course/Certification Award*
Please enter a value less than or equal to $1500.00.Life-time Maximum amount per person is $1500.
Indicate all other funding sources from which you are requesting support. Include the dollar amounts of other requests.*
Describe your plans for sharing the skills/information learned.*
Documents to Upload
Upload a flier, brochure describing the course/certification program.
Drop files here or

Max. file size: 2 MB.
Documents to Upload
Upload copy of the statement of support signed by you and your supervisor.
Drop files here or

Max. file size: 2 MB.
Documents to Upload
Upload receipts and/or course costs documents.
Drop files here or

Max. file size: 2 MB.
Note: If it is not possible to scan and upload documents, all documents may be placed in Mailbox 200.
- Uploaded all documents
- Document(s) were placed in Mailbox 200
Certification*
- I certify that I am the applicant and that I completed this form personally. I reviewed the application checklist and I am submitting all of the required documents.
- Send me a copy of my responses.