application. Please type in the appropriate field information. Handwritten forms will not be accepted. Please submit completed applications to Bobbie Fults at csac@uis.edu
or MS UHB 3100. Questions? Contact Bobbie Fults at csac@uis.edu
.
Name: __________________________________________________________________________________________
UIS Email Address: _____________________
Title/Description of Activity, course, publication, certification, etc:
___________________________________________________________________________________
Dates of Activity: ___________________________________________________________________________________
Please attach a detailed statement regarding the relevance of this activity to your profession, your professional
development at UIS and/or your unit: (250 words minimum, Please include event/activity website address if applicable.)
Please attach your supervisor’s Statement regarding the relevance of this activity for the employee and unit
(optional):
Total cost of activity: (approximate if necessary)
Cost share from home unit: (if any)
Total amount of CSAC Professional Development request:
$____________
$____________
$____________
This will be done on my own personal time: Yes No
Will you be able to participate in this activity without Professional Development Funding? Yes No
Name of Unit’s Fiscal Officer: (required) _________________________________________________________________
Unit Fiscal Officer’s Email Address: _____________

A detailed budget must be included for travel award requests. For specific and official travel reimbursement and per diem information, go to http://www.obfs.uillinois.edu/ .
Conference Registration
Hotel
Number of nights ______
Rate per night $ ________
Airfare
Taxes _____%
Mileage – Personal Car
_____ miles x $0.565
Date and Time you left Springfield
Date and Time you will return to Springfield
Taxis / Public Transportation
Per Diem
In-State ____breakfast x $5.50
In-State ____ lunch x 5.50
In-State ____dinner x $17.00
Out-of-State ____breakfast x $6.50
Out-of-State ____ lunch x $6.50
Out-of-State ____dinner x $19.00
Misc Expenses: ______________________
Total Expenses
Unit Contribution
Personal Contribution
$__________
$__________
$__________
$__________
__________
$__________
$__________
$__________
$__________
$__________
$__________
Hours worked in excess of full time hours *
Notes/Comments:
__________
*Guidelines:
• All UIS Civil Service status employees are eligible for funds.
•
In most cases, maximum funding is $1000 per person. However, if you apply for travel to a conference for which the registration fee is $600 or greater, you may request up to $1200 from this program.
• Reimbursements or charges must occur no later than June 30 th
• Funding will be reimbursed to a state account in the individual’s unit. Detailed instructions will be included with the award announcements.
•
*For non-exempt employees, compensable hours worked in excess of full-time will only be treated as compensatory time No overtime pay is allowed. Requires Supervisor Pre-Approval
Announcements on funding will be made no later than November 13, 2015

I certify that the information provided above is correct. I understand that university regulations, including travel regulations, will apply to any funding awarded.
Applicant Signature: (required) ____________________________ ____________ Date:
Supervisor’s signature: (required) __________________________ ______ Date:
Amount of CSAC Funding Approved $
Authorization:
CSAC