Revised 11/21/2010
Staff Revitalization and Professional Conference Funds
De Anza College Office of Staff and Organizational Development
Please download and complete this application on your computer (Faculty and Staff Computer Lab, LCW-16,
is available for those who need computer access). You must use Adobe Acrobat (or Acrobat Reader 5.0 or
greater) to fill in this application. Don’t forget to print a copy BEFORE you close this window, as Acrobat
Reader does not allow you to save the document.
********************* APPLICATION COVER SHEET *************************
Your Name: Extension or Daytime Phone #:
I have included the following with my application (please check all that apply):
1 Application Cover Sheet
1 filled-in and signed original application (signed by myself and my dean or supervisor)
1 copy of the flyer, brochure, or web pages that shows conference fees and hotel
costs, and a description of the activity.
A Yahoo/Google map showing the number of miles from the college or your residence
to the activity (whichever is closer).
7 additional copies of the application (printed back-to back).
1 copy of a completed International Travel Authorization Form (if you are planning to
travel outside of the United States).
APP NUMBER: Board Mtg Date For International Travel Approval:
Director, Staff and Organizational Development
Approved / Max Amount $ Not Approved Date:
FALL Deadlines: WINTER Deadlines SPRING Deadlines
Tue., September 20 Tue., January 10 Tue., April 10
Tue., September 27 Tue., January 31 Tue., May 1
Tue., October 18 Tue., February 21 Tue., May 22
[Winter Apps Start] [Spring Apps Start] [Summer Apps Start]
Tue., November 8 Tue., March 13 Tue., June 5
Tue., November 29
Revised 
Staff Revitalization and Professional Conference Funds
De Anza College Office of Staff and Organizational Development
Name: Today’s Date:
Division: Work Phone:
FHDA Email Address:
Check your Status: Classified/ACE Classified Hourly/ACE
Title of Proposed Activity:
Are you presenting at this activity? Yes No
Activity Date(s), Begins on: Ends on:
Activity Location, City: State: Country:
Check the appropriate description below for your activity:
A. Less than 150 miles from campus/work site, a one-day event
B. Over 150 miles from campus/work site, a one-day event
C. Less than 75 miles from campus, a multiple-day event
D. Over 75 miles from campus/work site, a multiple-day event
Please tells us specifically what you hope to learn or implement:
(i.e. create a system or process, develop new materials, improve your job skills, work collaboratively with
colleagues from another college or university, etc.)
Original receipts and proof of payment in the applicant’s name are required for reimbursement of
approved expenses. Sharing hotel expenses? Each attendee must pay for their own portion of the hotel bill
and have a receipt issued in their name.
Conference/Seminar Fee: $
[Maximum $500 for one-day activities less than 150 miles away from the
work site, or less than 75 miles away for multiple-day events; maximum
$1000 for one-day activities more than 150 miles away from the work site,
or over 75 miles away for multiple-day events]
Transportation: Airfare OR Mileage $
[For events you are driving to indicate which is closer to the event:
your residence: or your worksite
Enter the round-trip miles from home/work to the event: ;
Enter the number of days you will be travelling to the event: .
Reimbursement amount: round-trip miles x # of trips x $0.555/mile = ]
Ground Transportation
[Include public transit, round trip shuttle or taxi expenses from airport
to hotel, or car rental, where applicable] $
For local events, the committee recommends using public
transportation where possible.
Meals for All Days of the Activity $
[Maximums per day: Breakfast - $10, Lunch - $15, Dinner - $30.
Actual receipts do not need to be turned in. Meals provided by the
conference as part of the conference fee are not reimbursable. Meals
must be paid for by attendee; District ProCards may not be used for meals.]
Lodging $
# of nights @ $ per night (include estimated taxes) =
[Only for activities 75 miles or more away from the college.]
Total Costs: $
The committee strongly recommends that the applicant and manager discuss in advance
how the time away from the workplace for this activity will be reflected on the applicant’s
timesheet, if at all.
Please identify any additional District funding that you will be using for this activity (i.e. college grants,
VTEA funds, Impact/AAPI, B Budget, etc.), as they must be submitted on the same trip voucher
(name of fund/amount approved):
Signature of Applicant:
Signature of Supervisor: Date:
I certify that this applicant is not probationary and not on Staff Development Leave.
$ 0.00