EmailMe Form - Conference Reimbursement Scholarship Application

Conference Reimbursement Scholarship Application

Submission Deadline: February 1

To apply for the PENS Conference Reimbursement Scholarship, submit the following materials:
1. Completed application form (this form).
2. 2–4-page clinical exemplar OR copy of your poster abstract accepted by the PENS Research Committee. (Please attach Word document or PDF in the appropriate field below)
3.Letter from your employer clearly stating the amount of funding received from employer to attend conference. (Please attach document in appropriate field below)

Name *
First Last
Credentials
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
The above address is my: *
Phone *
### - ### - ####
Email *
Place of employment:
Position:
Type of submission (choose one): *
Are you receiving funds from your employer to attend? *
If you are receiving funds from your employer, please enter amount here:
Have you attended any PENS conferences? *
If yes, what years?
Are you a new member? (joined PENS within past 12 months) *
Have you presented a PENS poster in the past? *
Have you received a PENS Conference Reimbursement Scholarship in the past? *
If yes, please give dates (just list year(s) scholarship received):
Please upload a 2-4 page clinical exemplar OR a copy of your poster abstract accepted by the PENS Research Committee. *
Word (.docx) format preferred; will also accept PDF.
Please upload letter from your employer clearly stating the amount of funding received from employer to attend conference.
By signing below, I affirm that I will attend conference sessions if I am awarded this scholarship.
Clear