Medical Student Research Travel Award Adviser Form
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Student Information
Class
Name
Travel Information
Date(s) of Travel
MM-DD-YYYY format
Conference Name
Location
Departmental Funding
This student has contacted me about the travel opportunity and my submission of this form indicates my approval
Our department
is able to provide partial funding
is not able to provide partial funding
Budget Administrator Name
Contact Information
Amount of Funding
Enter "unknown" if the amount is unclear at time of submission
Research Adviser Information
Last Name, First Name, Degree
Department
Email
Phone
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