Professional Development Grant Applicants

Admin Information

Date Submitted: May 6, 2014

Application Number: PDG-2

Admin Decision:  Approved – Edit

Date of Decision: May 17, 2014

Decision Comments: 

50%

Applicant Information

Name: Monique Gore

Title/Position: Psychotherapist

Address Line 1: 3158 Eaton Rd

Place of Employment

Farm/Program Name: Oneida Tribe of Indians

Supervisor’s Name: Tina Baten

Supervisor’s Title: Clinical supervisor

Address Line 1: PO Box 365

Experience

Years in Position: 25

Average Hours Per Week: 40

Do you have any certifications or licenses? Yes

Certifications & Licensures:

Licensed Clinical Social Worker

Support Request

Is the request for a conference or meeting? Yes

Conference/Meeting Name: EAGALA Part 2 training

Hotel/Conference Center Name: Acres for Life

Provide justification for this request.

To complete certification

Provide a detailed budget.

Training fee is $650.00Transportation and accommodations $420.00

Other expected sources of support (including self-support).

Self

Signatures

I/we certify that all of the information contained herein is correct and true.

Applicant Signature: Monique Gore