DSC Professional Development Request Form

According to policy 3.9, the Faculty Excellence Committee will review professional development requests on September 1, December 1, and March 1.  After discussing your plans with your chair and dean, please complete this form and submit it to that committee chair for review.  Attach the Travel Authorization form (showing distribution of funds). Fill out the following as thoroughly as possible, then print and submit to the Faculty Excellence Committee. 

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Name: 

Department: 

Current Degree:

Year of current degree:

Tuition, Fees, or registration: 

Travel (air/ car): 

Housing: 

Meals: 

Other: _______________

TOTAL  funding requested: 

Purpose -- I am applying for Professional Development Funding to (click the option that applies best):

 

1.  If applying for funding to maintain licensure, how many credits do you currently hold?   

And how many credits remain for completion of licensure?   

Please describe the class(es), conference or training you'll pursue:

 

2.  If applying for funding to earn a terminal degree, in which discipline what was your most recent degree completed?   

And how many credits remain for completion of the degree you're pursuing?   

Please describe the class(es), conference or training you'll pursue:

 

3.  If applying for funding to present at a professional conference or workshop, whether local or regional, what is the title of your presentation?    

What is the conference name? 

What is the conference location? 

4.  If applying to attend or participate at a professional conference or workshop, local or regional, what is the

conference name? 

What is the conference location? 

5.  If applying for funds to pursue other objectives as determined by the division dean and academic vice president, please describe the class(es), conference or training you'll pursue:

 

Will you receive financial assistance from another source for this training or activity?    Amount: 

Source of other funding:  

In the space provided, please specify (a) how Dixie State College will benefit from this training and (b) how this training relates to your primary assignment at the College:

 

 

Faculty Signature: ______________________________  Date: _____________

Do not complete the following portion of this form:

Faculty Excellence Committee Recommendation:  Approve        Disapprove

Justification or comments: