Request for support from Region 8 IEEE Voluntary Contribution Fund 	ver9
The applicant: 

Name:						Surname:

IEEE membership number:				IEEE Societies membership:

IEEE membership grade (choose one only):   Student  -  Member  -  Senior member  -  Fellow

Address:

e-mail:				fax:

Volunteer activities within IEEE:

Gross income per year: 		$

Endorsement from an IEEE entity (Section or Chapter – not required for student members and committee members listed in Region 8 IEEE organizational roster):

Date and signature:						Office held:

The event: Please, describe the event 

Conference name, place and date:

Sponsored by IEEE Society – Section - Chapter:

Paper accepted for presentation (author(s) and title):

Conference web page:

Contact to conference organizers:

Did the conferece exempt you from conference fees?

Request for support from Region 8 IEEE Voluntary Contribution Fund – page 2.
Name of opplicant:  
Budget and bank information: 

Total cost of travel tickets and subsistance (US$): 
(please, add a detailed description overleaf or on a separate sheet of paper.)

Amount requested from R8 VCF:

Bank, bank address:

Account number:

Owner of the account:

Have you received support from R8 VCF in the past? If yes, state the amount, year and purpose: 

Do you require the money in advance? 

If the answer is yes, when do you need the money?

Signature

I understand that I have to report on the use of money to Region 8 IEEE VCF Coordinator, not later than one month after the event. This report must contain original receipts for all disbursements that have been covered from VCF money. All money from advance payments, that have not been used in accordance with VCF rules, are due back to Region 8 within two months after the date of the activity.
I agree that my name, conference name and amount of support provided may be published.

Applicant signature and date:						

Applicant checklist

I am a member of IEEE, I have paid my membership for this year.
The conference is sponsored by an IEEE entity (section, chapter, region or society).
I am the author of the paper to be presented.
I have filled all information to the form.
I have obtained a signature from the Section (Chapter) Excom (not applicable to students and section officers).
I have sent the form to r8vcf@mide.cz in electronic format (preferably .doc, .rtf, .pdf) (necessary condition for all applicant with internet access)
I have sent the hardcopy bearing original signatures to 
Prof. Zbynek Skvor, K317 FEL CVUT, Technicka 2, 166 27 Praha 6, Czech Republic.
I have read remarks attached at the end of this form
Remarks - applicant guide