FSA-School of Education and Health

FACULTY SCHOLARSHIP ACCOUNT (FSA)
Request Form 2025-2026

Name Name First Last
Requestor's Title

Full Professor, Associate Professor, Assistant Professor or Instructor.
Department
Email
Administrative Assistant email (will receive copy upon approval)
Pre-Approval Application

*please check the acknowledgment box below*
I acknowledge that all paperwork must be submitted within 30 days after my travel. I will submit all documentation to my department administrative assistant ASAP to allow them time to review. (IF APPROVED)
ITEMIZED ESTIMATE OF EXPENSES

*** SAVE and RETURN TO THIS FORM! HERE'S HOW: ***
1. 1. Check the box below to 'Save my progress and resume later'.
2. 2. Enter your email address when prompted, then click on the "Save form and resume later" button. You will receive an email with a return link.
Name of Conference/Event/Purchase:
Location (if applicable):
Foreign Travel?
If yes, please copy this link and complete this form as well
https://forms.brockport.edu/view.php?id=8746338

Foreign Travel? If yes, please copy this link and complete this form as well https://forms.brockport.edu/view.php?id=8746338 Yes No
Start Date: Start Date: / MM / DD YYYY
End Date: End Date: / MM / DD YYYY
TRANSPORTATION

*Travel must be in the best interest of the college and the most economical method of travel must be used. It is the traveler's responsibility to secure the most economical method of travel in the best interest of the State.*
Rental Car ($USD)
Personal Mileage ($USD)
Air Fare ($USD)
LODGING
Lodging ($USD)
MEALS AND OTHER EXPENSES
Meals ($USD)
Other Expenses (include miscellaneous):
No need to add dollar signs below.
Registration ($USD)

*If registration is not in USD Please convert*
I am requesting my registration to be paid early. I will contact Jessica Pruss (jlpruss@brockport.edu)
If not USD $ Please convert

I am requesting my registration to be paid early. I will contact Jessica Pruss (jlpruss@brockport.edu) If not USD $ Please convert Yes No
TOTAL
Total Amount of Funding Requested:
Please describe the purpose of your travel or purchase expenses: Explain in some detail how they advance your scholarship.
(attach agenda/proof of acceptance if conference). For reimbursement requests, once you receive this approved FSA form, please submit the appropriate NYS forms and supporting documentation (e.g., original receipts, invoices, etc.) to your department administrative assistant for review. After the department admin reviews your documents, they will be forwarded to the Deans Office for review and finally to procurement for processing.
Upload Supporting Documentation (up to 5 documents)
maximum 5 files whose total size may not be more than 10MB
filenames should not contain more than one period (.)
Upload Supporting Web Page (Link)
Type your full name as legal representation of your signature.
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

FSA-School of Education and Health

Pre-Approval Application

ITEMIZED ESTIMATE OF EXPENSES

TRANSPORTATION

LODGING

MEALS AND OTHER EXPENSES

TOTAL