Diversity, Equal Employment Opportunity Advisory Committee
Grant Application
General Information
Applicant Name:
Group Name (If applicable):
Email & Phone:
Today’s Date:
Event Name:
Event Date:
Projected Event Cost (total on budget excel sheet):
Please review the Diversity Certificate Guidelines. Do you hope to have your event qualify for
the diversity certificate? Yes No
Have you received funding for this event in the past? Yes No
List all other co-sponsors:
List all sources of funding:
Information Required if paying for Speakers/Third Party Performers***
Contractor/Company Name:
Email Address:
Tax ID or Social Security #:
***Include a bio or CV/resume of the speaker/3rd party performer
Purpose & Educational Value Statement
Please attach a document with the following:
1) List the goal(s) and/or action(s) that aligns Diversity plan that your event aligns with.
2) How does the event relate to your department’s, group’s, or organization’s mission?
3) Describe the educational impact of this event. How will this event benefit the Cerritos
College community.
4) In 250 words or less, please explain how your event connects to the Diversity and/or
Equal Employment Opportunity plans.
5) Optional: please provide any additional information that the committee should review
(event flyer draft, speaker vitae/resume, conference program, etc).
By submitting this form, I acknowledge that each of the following policies and rules will be met.
Within two weeks after the event ends; complete and submit to Donna Sheibe in the Office of Human
Resource Services the following:
i. Actual expense report
ii. Self-evaluation form
iii. Event Evaluations
iv. Original invoice(s) (signed by the requester) for payments made directly by the DEEOAC
v. A completed claim statement or petty cash voucher along with original receipt(s) for
reimbursement payments
All event advertising will include the following language for accommodations for ADA accessibility
“To request accommodations, please contact Dr. Valyncia Raphael at vraphael@cerritos.edu
c. All event advertising must include the DEEOAC logo and the Cerritos College logo
Name: Date: