NNYLN Professional Development Program Application

Please complete the following application and return to:
NNY Library Network
Business Office 6721 U.S. HWY 11
Potsdam, NY 13676

NAME: ___________________________________

EMPLOYER:________________________________

POSITION / TITLE: ___________________________

WORK ADDRESS: ___________________________

WORK PHONE: _____________________________

HOME ADDRESS: ___________________________

HOME PHONE: _____________________________

SOC.SEC.NO.: ____________________________

  1. Please name and describe the continuing education activity in which you wish to participate. (Attach flyer or brochure, if available).

    1. Title: ___________________________________

    2. Date(s): _________________________________

    3. Place: ___________________________________

    4. Sponsoring organization: ____________________

  2. Provide a brief narrative in the space provided on the following page explaining why you wish to attend this activity. You should address the following points: a) All successful applicants are required to share what they learned with the library community. Please indicate how you would be willing to share the knowledge or expertise gained through this activity. b) Please review the relevance of this activity to your current responsibilities and/or future professional plans. c) indicate whether you are applying for the entire cost of this activity or whether the cost will be shared through funds from other sources. If the cost will be shared, please indicate the source of the other funds.

  3. Budget

    Please provide a breakdown by category of the funds requested.

    Per diem rate of $39/day
    Number of days at $39.00

    _______________
    A. Registration or tuition funds _______________
    B. Travel expenses
    1. ___ Miles at $0.405
    2. Plane/Train/Bus
    3. Other (Specify)
    		 _______________
    _______________
    _______________
    C. Lodging _______________
    D. Meals_______________
    TOTAL REQUESTED (Maximum $500) _______________

    NOTE: ALL awards will be made on a reimbursement basis upon presentation of receipts.

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