Application for Professional Development Grant

Please type or write legibly

Print Name _______________________________

Today’s Date _______________

Position (teaching, patient care or administrative assignment)

Name of Event

(Please attach hard copy of program brochure or agenda)

Date(s) Location

1. What level of support are you seeking from Academic Affairs? Circle the appropriate choice. (Be specific; provide details below)

Full funding Release time Partial funding or Other

2. How will Palmer College, its students or the chiropractic profession benefit from your participation in this event?

3. How will your participation at this event support your personal/professional goals?

4. Are you willing to present information gathered at this event at a future faculty in-service or other venue open to all Palmer faculty? Yes No

a. If No, what is your specific plan to share information gained at this event with the Palmer Community?

5. Please indicate type of presentation (if any) Invited Paper      Contributed Paper      Poster Attendee only

6. Has this abstract been presented or submitted previously in any form? Yes No

a. If Yes, please list below the event name, location, date(s) and target audience:

7. Please type the title of your paper or poster below and ATTACH a copy of the ABSTRACT:

_____ Approved by Supervisor

_______________________________________________________________________

(print name) Signature

Optional supervisor comment:

Applicant (print name) _______________________Signature_____________________

Updated 7/2007