NAME:
HOME ADDRESS
CITY STATE ZIP
COLLEGE:
DAY PHONE:
EVENING PHONE:
JOB TITLE: DEPARTMENT: TEACHING DISCIPLINE:
EMPLOYMENT STATUS: FULL TIME PART TIME DATE OF HIRE:
No Work Time is involved in this requested activity.
( State Work is involved in this requested activity and has been approved by the employee’s supervisor.
EMPLOYEE SIGNATURE:
DATE:
TITLE OF ACTIVITY:
LOCATION:
(Authorization for Travel form must accompany this request.)
DATES OF ACTIVITY:
BEGINNING: ENDING:
COSTS OF ACTIVITY:
(Attach documentation.)
$ Registration Fee
$ Out-of-State Travel Expenses
$ In-State Travel Expenses
INDIVIDUAL PROGRAM INFORMATION: Provide a brief explanation of reason for participating in this activity and how it relates to
present work responsibilities:
I CERTIFY THAT IT IS MORE EFFICIENT FOR THE EMPLOYEE’S TRAVEL TO PROCEED FROM: (check one)
THE EMPLOYEE IS AUTHORIZED TO USE HIS OR HER PERSONAL VEHICLE.
YES NO
Supervisor’s Signature Date
* Whenever possible, CCSNH owned vehicles should be utilized for authorized business travel.
PLACE OF RESIDENCE
COLLEGE/SYSTEM OFFICE
COMMUNITY COLLEGE SYSTEM of NEW HAMPSHIRE
26 College Drive, Concord, NH 03301
REQUEST FOR PROFESSIONAL DEVELOPMENT
EMPLOYEE INFORMATION
(All employee information is required. Any spaces left blank will result in a delay in processing your request)
THIS REQUEST SHOULD BE SUBMITTED AT LEAST THREE WEEKS PRIOR TO REQUESTED ACTIVITY.
PROFESSIONAL DEVELOPMENT ACTIVITY INFORMATION
CERTIFICATE OF TRAVEL
CCSNH/College
OTHER: (Specify)
Source of Funds:
GRANT PROGRAM
IF GRANT-FUNDED, SPECIFY GRANT PROGRAM: PERKINS OTHER :
If requesting the use of Perkins Grant Funds, the Perkins Manager must complete
the Carl Perkins Grant Authorization section below.
APPROVED DENIED APPROVED DENIED
Explanation: Explanation:
Signature-Supervisor Date
Signature-CCSNH/College Appointing Date
Authority or Designee
FUNDING REQUEST
INSTITUTION APPROVALS
CARL PERKINS GRANT AUTHORIZATION
CARL PERKINS FUNDING
COMPLETE THE FOLLOWING: (Completed by CP Project Manager Only)
Program Improvement Funding: Please describe how the proposed staff development activity will improve career and
technical programs. Check all staff development characteristics below that apply and provide additional comments:
o in use of state of the art technologies, e.g., distance learning
o in state of the art vocational and technical education programs
o in techniques in effective teaching skills based on research
o in effective practices to improve parental and community involvement
o in staying current with all aspects of the industry
o internship program that provides business experiences to educators
o in the use and application of specific technologies (described below)
Comments:
Signature – Perkins Project Manager Date
Revised 7/07/14
Original to Business Office
Copy to employee
Copy to HR Office or
Staff Dev Committee
Print Form
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