APPLICATION FOR FINANCIAL SUPPORT

Future Trends in Geometric Function Theory Workshop

at the University of Jyväskylä, Finland

June 15-18, 2003

Please furnish your name, residential address (domicile), Social Security number, and signature. Also, provide both addresses, and check the address to which you want your check mailed. Please return this form with receipts to: David Herron, Department of Mathematics, University of Cincinnati, Box 210025, Cincinnati, Ohio, 45221-0025, david.herron@uc.edu 1-513-556-4075.

FULL NAME (Please Print): __________________________________________________

Email Address: ______________________________________________________________

( ) HOME MAILING ADDRESS (Please Print) ( ) PROFESSIONAL MAILING ADDRESS (Please Print)

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

______________________________________________ ______________________________________________

_____________________________________________ ______________________________________________

POSITION ( ) Graduate Student ( ) Untenured Faculty, or Post Doctoral Position

( ) Tenured Faculty ( ) Other: _____________________________________

EXPENSES: Please fill in the expense report on the reverse side of this form. Total $

I certify I have incurred the above expense.

SIGNATURE: _________________________________________ TIN/Soc. Sec. No.: ___________________________

(required for reimbursement)

DO NOT WRITE BELOW THIS LINE

To be completed by the organizer: This form authorizes the University of Cincinnati to pay from the National Science Foundation Future Trends in GFT Workshop Grant the above named person the sum of $__________ for expenses incurred to attend the Future Trends in GFT Workshop at the University of Jyväskylä, June 15-18, 2003.

David Herron, Workshop Organizer
Expense Report

Future Trends in Geometric Function Theory Workshop

at the University of Jyväskylä, Finland

June 15-18, 2003

Eligible items for reimbursement include airfare, local transportation, lodging and meals. You must provide original receipts for airfare, local transportation and lodging. Please enclose receipts with this form and send to the address given on the other side.

Itinerary

Outbound Trip	Location	Date and Time
Departure:
Arrival:
Return Trip
Departure:
Arrival:

Transportation Costs

Method of Transportation	Amount
Air Travel
Local Transportation
Other (indicate type)

Lodging

Number of Nights

Price per Night

Total

Meals

Meal	Number of Meals	Rate	Amount
Breakfast		$6
Lunch		$9
Dinner		$15