Professional Development Fund Application Form

Date*
MM slash DD slash YYYY
Name*
First Last
UH Email Address*
Office Extension Number*
Position at UHMC*
Number of Years at this Position*
Name of Activity*
Beginning Date of Acvitity*
Location of Activity*
Briefly describe the nature of this activity and the impact that it will have on you, your department, UHMC students, UHMC Strategic Plan and/or 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 Faculty & Staff Development Fund*

Please enter a value less than or equal to $2000 ($2500 for first time applicants). Maximum amount per person for two years is $2000 ($2500 for first time applicants).
Indicate all other funding sources from which you are requesting support. Include the dollar amounts of other requests.*
Describe your plans for sharing the information learned.*
Documents to Upload
Upload a flier, brochure or invitation describing the activity, including agenda of the activity
Max. file size: 10 MB.
Documents to Upload*
Upload signed verification statement from your supervisor/dept. chair that shows awareness of and support for your F&SD Fund application.
Drop files here or

Max. file size: 10 MB.
Documents to Upload
Upload copy of travel request form signed by you and your supervisor/dept. chair
Max. file size: 10 MB.
Documents to Upload
Upload receipt/reservation documents
Max. file size: 10 MB.
Documents to Upload*
- Uploaded all documents
- Document(s) were placed in Mailbox 200
Upload signed verification statement from your supervisor/dept. chair that shows awareness of and support for your F&SD Fund application.
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.