UNIVERSITY OF CONNECTICUT HEALTH CENTER

OFFICE OF THE ASSOCIATE VICE PRESIDENT FOR RESEARCH ADMINISTRATION AND FINANCE

GRADUATE STUDENT TRAVEL GRANT REQUEST

Applicant’s Name:______________________________________________________________________

Faculty Sponsor ________________________________________________________________________

Department/Division: _____________________________Mail Code: ________ Phone # ________

Contact Person Name & Phone # _______________________________________________________

Travel Period:___________________________Destination: __________________________________

Title of Paper:  _________________________________________________________________________

_________________________________________________________________________________________

Relationship to Thesis: ________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Professional Society:___________________________________________________________________

Purpose of Travel: (  ) Presentation of an Invited or Contributed Paper

                             (  )  Presentation of a Poster

Cost of Trip:  $_____________________Amount Requested from HCRAC:  $________________

•Attach copies of abstract, registration information, proof of acceptance and/or letter of invitation and other supporting documentation (e.g. program announcement).

•Requests, accompanied by the travel authorization, should be submitted to the Office of the Associate Vice President for Research Administration and Finance, UCHC,  MC-2806, at least 4 weeks prior to the date of departure, if possible.

_________________________________________       ____________________________________

          Applicant’s Signature                                Faculty Sponsor Signature