Travel Sponsorship Application Form
ICC Final Comment Hearings, Kansas City, Missouri, October 19-25, 2016
ICLEI-Local Governments for Sustainability USA

**Your voting representatives must have been registered with the ICC by September 19 in order to vote **
To review your Governmental Member Voting Representatives voting credential status, go to: https://av.iccsafe.org/eweb/dynamicpage.aspx?webcode=OrgVoterReg&Site=icc

Pre-Application Instructions
1)	Verify that your community is an ICC member at 888-ICC-SAFE, ext. 33804 or http://www.iccsafe.org/Membership/Pages/RenewReinstateMembership.aspx 
2)	Check your list of voting representatives eligible to vote at the Kansas City Final Comment Hearings as described above; 
3)	Review Compliance with ICC Policies, especially CP36-09, Financial Assistance: See: http://www.iccsafe.org/membership/chapters/cp-36/
Or see: http://productionpullzone.umz7izwbxixtqs4tn8wkvgdcktq5y5tafr.netdna-cdn.com/wp-content/uploads/CP36-09.pdf
4)	Seek approval of elected governing body or chief administrative officer of your jurisdiction to accept travel support to the ICC hearings in Kansas City.
Application Instructions
1)	Review and complete the one page form below, signing where indicated.
2)	Submit a scanned copy to ICLEI USA at riana.ackley@iclei.org 
3)	ICLEI will review applications on a rolling basis as received; funds will be provided on a first-come basis while available. 
4)	The scholarship amount will be up to $1000 per GMVR.  Priority will be given to those that are not receiving travel assistance from another source, and plan on attending the International Energy Conservation Code (IECC) portion of the hearings (Oct 19-22.)
Terms and Conditions
1)	ICLEI USA is providing travel scholarships to local governments for the express intent of enabling qualified local government officials (GMVRs) to attend the ICC Final Comment Hearings in Kansas City, MO, October 19-25, 2016. While the travel scholarship is intended to partially cover expenses of the individual traveler, the expense reimbursement payment will be made only to the local government (i.e. the traveler’s employer.) Membership in ICLEI USA is not required to apply for travel support.
2)	By signing below, the elected governing body representative or chief administrative officer agrees that:
a.	The jurisdiction is a current member the International Codes Council.
b.	The jurisdiction has reviewed Compliance with ICC Policies and will comply with all ICC policies, especially CP36-09, Financial Assistance.
c.	Acceptance of travel support is not contingent on support for sponsors’ positions and there is no expectation of favorable voting in return for travel support.
d.	Travel assistance is provided only to allow local government officials to participate in code development hearings.
e.	Acceptance of this travel scholarship will comply with all local policies for accepting financial support from outside organizations.
f.	Acceptance of this travel scholarship will comply with all local travel policies and applicable law.
g.	The jurisdiction will comply with all ICLEI policies and instructions for receiving travel scholarships and reimbursement or risk forfeiting this financial assistance.
3)	Reimbursement of expenses directly to individuals is prohibited by ICC policies and rules.  ICLEI will only make scholarship payments to ICC governmental members (e.g. local jurisdictions).  Local governments then pay for travel expenses or reimburse their delegates.  
Questions? Contact Riana Ackley at riana.ackley@iclei.org.
Travel Sponsorship Application Form – ICC Final Action Hearings, Kansas City, Missouri, October 2016
ICLEI-Local Governments for Sustainability USA
Jurisdiction Overview
Name and Type of Local Government (i.e. City of Smithville)		
Current Governmental Member of the International Code Council  	□ Y                                 □ N 	
Current member of ICLEI USA	□ Y                                 □ N	
Have you summited your list of delegates to ICC?	□ Y                                 □ N	
Population of Jurisdiction 		
Maximum Number of ICC Voting Representatives (4, 8 or 12)		
Number of individuals for whom travel support is requested		

Please Circle Days GMVR Travelers plan to be at ICC/IECC hearings in Kansas City
Wed Oct 19	Thu Oct 20	Fri Oct 21	Sat Oct 22	Sun Oct 23	Mon Oct 24	Tue Oct 25	
Admin IECC-R	IECC-R	IECC-C	IECC-C				

Proposed Local Government or Jurisdiction GMVR Travelers
1	PRIMARY TRAVELING DELEGATE (see below)
Name:
Position:
Email:
Telephone:
Mobile phone:	2	Name:
Position:
Email:
Telephone:
Mobile phone:	
The primary travelling delegate is requested to serve as a coordinator for the jurisdiction’s delegation before, during and after the Final Action Hearings in Kansas City to facilitate the communication of important information.

Elected Governing Body Representative or Chief Administrative Officer Authorization
To comply with International Code Council policies for contributions to ICC governmental members, travel scholarships must be accepted with the explicit authorization of the elected governing body or chief administrative officer (e.g. a Mayor or City Manager). The official’s signature below constitutes authorization. This authorization is not a commitment to attend the ICC hearings, and the local government may decline the offer of travel support that will be made after processing of the application.
Name		
Title/Position		
Mailing Address		
Telephone		
Email		
Signature		

The Applicant(s) certify that I/We have reviewed and followed the Pre-Application and Application Instructions, and that I/We have reviewed and accepted the ICLEI Terms and Conditions as set forth above.

Applicant Name and Signature: _______________________________________     Date: ______________