Name:       Today's date:

Faculty   Student

Organization Hosting Conference: 

Location & Dates of Conference: 

Indicate whether the conference is Regional/ National/ International:   Regional   National   International

Will you be presenting?   Yes   No

Title of Presentation: 

Name of Co-presenter(s): 

If you are not presenting, please provide a brief description of why you believe it would be beneficial for you to attend:

Amount of travel funds requested:

Provide justification for your requested amount: