Fillable Form 601: Ursinus College INTERNAL )(//2:6+,3 FORM (Ursinus College)

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Form 601: Ursinus College INTERNAL )(//2:6+,3 FORM (Ursinus College)

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The Form 601: Ursinus College INTERNAL )(//2:6+,3 FORM (Ursinus College) form is 2 pages long and contains:

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File type: PDF

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Ursinus College
601
E. Main
Street
• Collegeville,
Pa
. 19426
ursinus.edu
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__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
INTERNAL )(//2:6+,3 FORM
Completion of this form indicates official sanction of the outgoing application. Please obtain
signatures on the second page and submit signed form to the Advancement Office five
business days prior to the due date.
Submission Deadline: __________________ Electronically? Y or N
)(//2:6+,3 DATA (a copy of the fellowship application must be attached):
Faculty/Principal Investigator:
Department: ________________________________________________________________________________________________________
Foundation, Agency, Program Name _____________________________________________________________________________________
Proposed Start Date of fellowship, if awarded: ___________ Proposed End Date of fellowship, if awarded: _______________
BUDGET (You must provide a detailed draft budget)
PI, Key Personnel, and Chair(s) are responsible for adhering to College policies and procedures; accepting responsibility for excess
expenditures and disallowed costs; ensuring all costs incurred are project related and in accordance with any terms, conditions and time frames,
and ensuring the technical and reporting requirements of the project are satisfied.
Fellowship Request: $__________________________
College Match / Cost-Sharing Request: $__________________________
Project Total $__________________________
College to supply required cost-sharing. The amount is: $ __________________
College to supply voluntary cost-sharing. The amount is: $ _________________
This fellowship includes a request for academic year release time. (Attach justification, see instructions)
CONFLICT OF INTEREST (Completed Form Must Be Attached (link here)):
There is a potential "significant financial interest" related to this project, detailed in the attached.
There is NO Conflict of Interest. The disclosure policy form is signed and attached.
PUBLICATION/PRESS
I would like to be interviewed for publication/press: Y or N
REMARKS:
Account Number(s): ____________________________
Account Number(s): ____________________________
(note: any cost sharing must include an account number to charge cost-sharing and the appropriate sign-off below)
Requested course(s) to be released: ________________________________________________________________________________
COST SHARING:
REQUEST FOR COURSE RELEASE
PROFESSIONAL LEAVE
Anticipated length of professional leave: _________________________
Preferred time period of professional leave: __________________________
Ursinus College
601
E. Main
Street
• Collegeville,
Pa
. 19426
ursinus.edu
_____________________________________________
_____________________________________________
_____________________________________________
_____________________________________________
Fellowship ROUTING:
Electronic signatures are acceptable. Signatures should be obtained in order. Advancement Office will sign upon submission of
the ĨĞůůŽǁƐŚŝƉĂƉƉůŝĐĂƚŝŽŶ.
I assure that all of the above information is correct to the best of my knowledge. I certify that statements made on this form
indicate that the application is in accord with the academic standards and goals of the originating department, the institutional
policies of the department and Ursinus College, and the policies and/or governing regulations of the sponsoring agency.
I agree that the final application may be shared within Ursinus College as a learning tool. I agree to readily supply officers
of the institution with all copies of my reviews, and understand that these may be shared within the college to improve future
applications.
Ursinus Faculty / PI: ________________________________________________________
The attached application has been examined by the officials whose signatures appear below. The principal academic review of
the application is the responsibility of the Department Chair and College Dean. These signatures indicate that the signers are
familiar with the application, and except as noted and initialed in the remarks section, are satisfied with and responsible for all
commitments in the application as they relate to their respective areas (e.g. space, personnel, financial, etc.).
1. Department Chair
Of PI’s department
2. Dean of the College
Or delegate
Academic Affairs
3. Business Officer
Business Office
4. Advancement/
Corporate, Government, and Foundation Relations
Officer
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Form 601: Ursinus College INTERNAL )(2:6+,3 FORM (Ursinus College)

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Completed 24 July 2020

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