Bemidji Regional Interdistrict Council

1) Name:

2) Email:

3) Todays Date/Time

4) BRIC Supervisor:

6) Explanation:

7) Date & Time of Absense

8) Are you taking Full Days?

YES

NO

9) Total Full Days :

10) Are you taking hours?

YES

NO

11) Total Hours

12) Professional Leave (MUST complete if taking professional leave): (optional)

Please attach registration form & workshop/conference description. (If a PO can be used contact Lori Bradseth, 218-751-6622 or lbradseth@bric.k12.mn.us for PO #)

I will register myself

If lodging is necessary, I will arrange my own lodging.

13) Cost of Registration (MUST complete if taking professional leave): (optional)

*Once approved, complete a Reimbursement form and email to lbradseth@bric.k12.mn.us along with registration confirmation & payment receipt. Reimbursement will be completed after event date.

14) Office Use Only BRIC Supervisor (optional)

Approved with Pay IF Leave Available -- If no leave available, approved without Pay

Not Approved

15) BRIC Supervisor Signature (optional) Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

16) Date (optional)

17) Executive Director (optional)

Approved with Pay IF Leave Available -- If no leave available, approved without Pay

Not Approved

18) Executive Director Signature (optional) Signature

I understand that my typed signature is the legal equivalent of my handwritten signature on this document.

19) Date (optional)

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