Last Name: First Name:

Email:

Event: City:

Start Date: End Date:

Presenting a paper/performance? Yes No

Officer of organization? Yes No

Indicate amount of honorarium you are receiving:

Amount of transportation funds requested

Registration Fee (max $75.00)

IN-STATE SUBSISTENCE

Day One (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($15.75) Lodging ($59.75)

Day Two (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($15.75) Lodging ($59.75)

Day Three (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($15.75) Lodging ($59.75)

OUT-OF-STATE SUBSISTENCE

Day One (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($17.75) Lodging ($71.00)

Day Two (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($17.75) Lodging ($71.00)

Day Three (mark all that apply)

Breakfast ($7.00) Lunch ($9.25) Dinner ($17.75) Lodging ($71.00)