PGSG TRAVEL GRANT APPLICATION FORM Spring 2012

Deadline: Friday, March 2, 2012 First Name: Academic Department1:

1

Last Name:

do not abbreviate

College or School2: Agriculture / CFS / Education / Engineering / Liberal Arts / Management / Pharmacy, Nursing, Health Sciences / Science / Technology / Veterinary Medicine/
2

Please make choice bold. If you are in an Interdisciplinary program please bold the School of your Major Professor

Campus: West Lafayette / Indianapolis (IUPUI) / Fort Wayne / Calumet / North Central Email Address: Title of Presentation:

Name of Conference:

Dates of Conference3:
3

For this grant cycle, travel must be between 3/1/12 and 8/31/12

Location of Conference: Was this research conducted at Purdue? Yes / No

Will you be presenting this paper (i.e. giving the talk, standing at the poster, etc.)? Yes / No Budget (Copy from Page #2): Total Costs: $ Total Support: $

Faculty Advisor Read and Provide Electronic Signature: I certify that I have read this travel grant application, including the budget, that the applicant is my student and is a graduate student at Purdue in good standing, that all information in this application is accurate to the best of my knowledge, the budget is realistic, and this student is likely to attend and give this presentation at this conference. Faculty Electronic Signature: Date:

Applicant - Read and Sign: I certify that I have read and agree to the current rules and directions for the Travel Grant program and certify that all information I have provided in this application is accurate. I further grant permission to the Travel Grant Committee and the Graduate School to verify my status as a graduate student in good standing at Purdue and my eligibility for the Travel Grant Competition. Applicant Electronic Signature: Purdue ID#4:
4

Date:

not Social Security number

Travel Costs Travel: Airline Ticket or Ground: or Other (specify): Conference Registration: Lodging: Meals: Total Travel Costs $ per night x nights occupants days @ $26 per day (international rates may differ) $ $ $ $ miles @ $0.555/mile (or current rate) $

Travel Support: Indicate all sources and amounts of funding which will be applied toward attending this meeting. Please do not include funds you hope to get from PGSG. Department Advisor / Faculty Research Grant Professional Society Travel Grant Other Total Travel Support Applicant Contact Information: Phone#: Daytime: Evening: $ $ $ $ $ $

Faculty Advisor Contact Information: Department: Email Address: Phone Number:

See Directions for more information. Submit application through email to Sam Peterson PGSG Travel Grant Chair smpeters@purdue.edu

PGSG TRAVEL GRANT RESEARCH STATEMENT - Spring 2012

Title of Presentation:

Name of Conference:

Research Statement (use 10 pt. font or greater)