This form is also available as a PDF. Email completed PDF forms to jacklyn@calact.org RTAP Scholarship Application (PDF)Download Online Application Name(Required) Title Phone(Required)Email(Required) Organization to be reimbursed(Required) Address (To submit payment)(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Seminar, Course, or Conference(Required) Location City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Starting Date(Required) MM slash DD slash YYYY Eligibility QuestionsI receive the following funding sources: 5310 5311 5307 The population in my county is: 50,000 or less 50,000 to 150,000 150,000 to 250,000 Over 250,000 Organization Type Non-Profit Government Organization For-Profit Tribal Government Other Agency DescriptionProvide a brief description of your service area and services providedTraining Program DescriptionPlease provide a short description of the training program you are attending, and why it was selected compared to other training programsExplain how your attendence will benefit your organization:Estimated ExpensesRegistration FeeMileageLodging (Number of nights)Location (County) of HotelUsed to calculate per diem rates, as per state guidelines Alameda, San Francisco, Santa Clara, or San Mateo County Los Angeles or San Diego County None of the above Airfare or Rail TicketsMust be purchased 14 days in advance. Maximum reimbursement for tickets purchased less than 14-days in advance will be based on mileage at a rate that is the same as the automobile mileage reimbursement.Other Transporation ExpensesTolls, Parking, Taxi, Public TransitCar Rental*Not reimbursed, but can count toward the match requirement (see below). State per diem rates: $50/day, up to a max of $300Please enter a number less than or equal to 300.Meals*Not reimbursed, but can count toward the match requirement (see below). State per diem rates: $6 per breakfast, $10 per lunch, and $18 per dinnerHiddenIRS RateDefault 2021 IRS mileage reimbursement rateHiddenLodging ExpensesHiddenMileage ExpensesTotal Estimated ExpensesTotal Reimbursable ExpensesYou may be required to justify travel mode based on factors such as mileage or airfare cost and lodging nights required. Maximum reimbursement for tickets purchased less than 14-days in advance will be based on mileage at a rate that is the same as the automobile mileage reimbursement. Please attach a Mapquest sheet with mileage from work place to training site. Caltrans has provided additional RTAP scholarship funds for the contract which require a minimum of a twenty percent match. The match must be paid by the agency requesting a scholarship. The cost of meals and rental cars at the state rate are not reimbursable from the scholarship fund but can be used toward the match requirement. Consent(Required)I authorize CALACT to store my information for purposes of this application. Personal information will not be shared with 3rd parties, or used for purposes other than this application. I agree to the privacy policy.Certification(Required)By submitting this application, I certify the provided information to be true. I realize that if my expense forms are not turned in within 30 days, my agency may not be reimbursed for any incurred training expenses. In addition, if I am deemed ineligible for the scholarship, my agency may not be reimbursed for the expenses. I certify all of the above.NameThis field is for validation purposes and should be left unchanged.
