Sponsoring Body: _______________________ Contact:  ________________________________

Phone:_______________   Course name:_____________________________________________

Recognized by Education/Campaigns Dept?    [   ] Yes      [   ]  No

If no, date submitted to Head Office:________________________Sent to:__________________

Number of Participants expected:__________________Total hours in class:________________ 

Date(s) and times:_______________________________________________________________

Course facilitator:_____________________________________Phone:  ____________________

Expense Information

This application is submitted to the Region ___ EBM/Staff group.  We understand that, if approved, funds sufficient for the educational to be delivered will be forward to _________________________

These funds are in trust, and we agree to forward a final copy of this form with actual costs, together with all receipts and expense claims to document the costs.

We agree that OPSEU offers no guarantee to cover budget overruns.  We agree that any funds not spent on this educational shall be returned as soon as practical to OPSEU.

Signature:_______________________  Position _______________________ Date:  ______________
Signature:_______________________  Position _______________________ Date:  ______________
On behalf of:  _______________________________________________________________________