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Administrative Information

THIS IS A...
New Request
Revised Request

NAME:

ADDRESS:

DEPARTMENT:

PHONE # FAX #

E-MAIL ADDRESS:

Event/Program Information

EVENT/PROGRAM NAME:

PLEASE SELECT THE TYPE OF EVENT: Meeting Conference Training Session Work Shop

DATE OF EVENT:

START TIME: END TIME:

EVENT INSTRUCTOR/FACILITATOR:

INSTRUCTOR/FACILITATOR PHONE #:

IF EVENT RECURS, PLEASE COMPLETE THE FOLLOWING, otherwise, leave blank

START DATE: END DATE:

DAY(S) EVENT RECURS
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Site Information

Please complete the information for each site involved, otherwise, leave blank.

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ORIGINATING SITE: select one

Twin Cities Duluth Crookston Morris Rochester Other
Identify "other" if selected

# OF PARTICIPANTS:

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1st RECEIVING SITE: select one

Twin Cities Duluth Crookston Morris Rochester Other
Identify "other" if selected

# OF PARTICIPANTS:

SITE PROGRAM CONTACT:

CONTACT'S PH #:

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2nd RECEIVING SITE: select one, if needed

Twin Cities Duluth Crookston Morris Rochester Other
Identify "other" if selected

# OF PARTICIPANTS:

SITE PROGRAM CONTACT:

CONTACT'S PH #:

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3rd RECEIVING SITE: select one, if needed

Twin Cities Duluth Crookston Morris Rochester Other
Identify "other" if selected

# OF PARTICIPANTS:

SITE PROGRAM CONTACT:

CONTACT'S PH #:

-------------------------------------------
4th RECEIVING SITE: select one, if needed

Twin Cities Duluth Crookston Morris Rochester Other
Identify "other" if selected

# OF PARTICIPANTS:

SITE PROGRAM CONTACT:

CONTACT'S PH #:

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PLEASE NOTE ANY SPECIAL ARRANGEMENTS
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Billing Information

*** FUND: *** DEPT ID: ACCOUNT: *** PROGRAM: PCBU: PROJECT:

ACT: CHART FIELD 1: CHART FIELD 2: FIN EMPL ID: CST SHR:

DIRECT BILLING ADDRESS
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