Name of applicant: Date:

Name of affiliated organization (if applicable):

University mailing address:

Penn State E-mail address:

Telephone number: -

Amount of funding requested:

Please describe how the funds will be used:

What is the anticipated outcome for your project/event?:

The following information will help to assist us in our decision making process:

Total funding needed for your project/event:

Have you requested funding from other sources?: Yes No

If yes, please complete the following:

Please explain how your request supports the mission of the Commission on Racial/Ethnic Diversity:

If an interdepartmental transfer can be processed for your request, please provide the appropriate IDCC ID number:

If your funding request supports a registered student organization, please provide the appropriate ASA account number: