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Student Travel/Housing Awards Application

Fields marked with * are required.

Student Travel/Housing Award Application
Student Information
Student Name *
Gender (for housing assignments) *
Male
Female
Address *
City *
State *
Zip Code *
Phone *
Fax
E-Mail *
Student Type *
Graduate
Medical
Undergraduate
Degree Expected *
PhD
MD
MS/MA
BS/BA
Currently an AChemS Member? (Membership is Required) *
Yes
No
Have you received previous travel/housing assistance? *
Yes
No
If Yes, did you receive: (Check all that apply)
Year Received
Are you presenting a poster or speaking? *
Yes
No
Type of Assistance Requesting: (Note: You can only apply for Housing *OR* Travel Award)
Housing
Travel
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Advisor Information
Advisor Name
Advisor Title
Mailing Address
City
State
Zip Code
Advisor Phone
Advisor Fax
Advisor E-mail
Advisor Currently an AChemS Member?
Yes
No
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Travel Assistance Requests -- (Please complete the following)
AIR TRAVEL
Air Travel: Lowest round-trip fare:
City of Origin
AUTO TRAVEL
The following itemized budget is required if requesting assistance with automobile travel. List expected expenses incurred when traveling to and from Sarasota only; do not list expenses incurred while at the meeting. If more than one student travels in the same automobile, expenses for only one traveler can be claimed. The amount of the automobile travel award will be based on a percentage of lowest available airfare, or the actual amount requested, whichever is lower.
Car Rental Fees:
Gas:
Food:
Estimated # of Miles:
Lodging Expenses:
Number of Nights:

*Please be sure to print out your confirmation and keep for your records.



 

 
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