Staff Development Scholarship APPLICATION

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Staff Development Scholarship APPLICATION

Date:

Name:

Home Address:

City:

State:

Zip Code:

Home Phone:

Business Phone:

E-Mail:

Date Hired:

Work Location:

Department:

Zot Code:

If UCIMC, employee's Route #:

Employee #:

Payroll Title:

Title Code:

Estimated budget for activity: $

Have you received this same scholarship in the past?

Yes, What year? Amount?
No

If you received an award in the past, future eligibility is as follows:

Year Received	Year Eligible
2003-04	2006-07
2004-05	2007-08
2005-06	2008-09
2006-07	2009-10

Please specify how your proposal relates to your plan for career development and advancement at UCI. Explain your planned activity stating the date, duration, and location and cost.

Send proof of costs, registration, (i.e., copy of a catalog page or brochure showing registration fees, etc.) of planned activity to:

Staff Development Scholarship
Equal Opportunity & Diversity
103 MSTB
Irvine, CA 92697-1130

SURVEY DATA Female Male

Please mark the category that best applies.

American Indian/Native Alaskan
Black/African American
Hispanic (Latino/a, Mexican, Chicano/a, Spanish)
Asian (Chinese, Filipino, Japanese, Pakistani, East Indian, other Asian)
Pacific Islander
White/Caucasian

Disability/Impairment
No Disability

Please mark the category that best applies.

Special Disabled Veteran
U.S. Vietnam Era Veteran
Other U.S. Veteran
Does not apply

Submit online or print and send to:

Staff Development Scholarship
Equal Opportunity & Diversity
103 MSTB
Irvine, CA 92697-1130

If you have questions, please drop by the office or call (949) 824-5594.

Privacy Notification
The State of California Information Practices Act of 1977 requires the University to provide the following information to individuals who are asked to supply information about themselves: The principle purpose for requesting the information above is to determine eligibility for an employee development scholarship award. University procedures authorize maintenance of this information. Furnishing all the information is mandatory. Failure to provide such information may prevent completion of the action for which the form is being filled out. Information furnished on this form may be used by various University departments for reimbursement purposes and will be transmitted to the State and Federal governments if required. Individuals have the right to review their own records in accordance with staff personnel policies MAP 60, A&PS 160, or SP 605. The official responsible for maintaining the information contained on this form is the Director of Equal Opportunity and Diversity, University of California, Irvine, CA 92697 - 1130.