Phi Sigma Society
Student Research Travel Grant Application

Student (print) ______________________________ Member/year _______ or Inductee ____ Chapter _______________

Address:   _______________________________________________________________________________________

_______________________________________________________________________________________________

Faculty Mentor (print) ________________________ Member/year _______ or Inductee ____ Chapter _______________

Title of Presentation: ______________________________________________________________________________

______________________________________________________________________________________________

Author(s)/Presenter(s): ____________________________________________________________________________

Professional Meeting: _____________________________________________________________________________

Location: ____________________________________________ Date(s) of meeting: ____________________________

Student Registration fee: _________   Travel cost @ $0.34/mile, or airfare (explain):  _______________________________

Lodging cost (explain): _____________________________________________________________________________

Publication: _____________________________________________________________________________________

Copy of publication included ____ or will be forwarded to regional V.P. and the National Headquarters ____

Student signature: _____________________________   Chapter Advisor authorization: __________________________

Number of students in Chapter's last initiation class (REQUIRED): _________  Today's Date: _________________________

Date received by Executive Director:  ________________   Acknowledgment of receipt sent to student:  _____________

Accepted by Executive Director (if no, explain):

Date forwarded to National Headquarters: Approved by National Headquarters: