Instructions for Application:

1. Complete the following application form, printing legibly.
2. Attach a copy of the completed Course Brochure/Registration form, front and back.
3. Send completed application with attachments to the current PNWSGNA Scholarship Chair (contact information located on www.pnwsgna.org).

Contact Information

Name:______________________________________________________________

Credentials:__________________________________________________________

Home Address:_______________________________________________________

City:___________________________State:________Zip Code:________________

Home Phone:_________________________________________________________

E-Mail Address:_______________________________________________________

Employer:____________________________________________________________

Employer Address:_____________________________________________________

Work phone:_______________________Work Fax:__________________________

Name of immediate Supervisor:___________________________________________

May we contact him/her for information if needed?     Yes_____              No________

How would you prefer that we contact you?           Home_____           Work________      

PNWSGNA Membership Information

1. How long have you been a member of PNWSGNA?_____________________
2. How long have you worked I the field of gastroenterology:________________
3. Have you received a PWNSGNA Continuing Education Scholarship in the past?

____Yes – list the years that you received the scholarship__________________

             _______________________________________________________

____No

Program Information (attach copy of both sides of brochure)

4. What is the title of the continuing education program you would like to attend?

      ________________________________________________________________

5. Who is the Provider for the above program?________________________________
6. What is the date(s) of the program?_______________________________________
7. Where is the program being held (city & state)_______________________________
8. How much is the Provider charging for registration?___________________________                 

Personal Statement – Please write a brief description of the activity, including:

• Why you want to attend it (what are your goals for attending the conference?)
• How this event will help you in your work
• How you will share your experience with co-workers
• Any other special circumstances, including financial hardship

_____________________________________________________________________________________

Terms of Agreement

            I understand that, if I receive a PNWSGNA Continuing Education Scholarship, I am required to apply funds received toward the registration expenses for the aforementioned program.  If I do not attend the course, I understand that any scholarship funding will be revoked.  I understand that funds will be dispersed from by PNWSGNA Treasurer upon completion of the program and upon completion of:

1.  Submission of a copy of my Certificate of Attendance to verify the attendance at the program, sent to the PNWSGNA Scholarship Chair within 30 days of program, and

2.  Submission of an article to the PNWSGNA Newsletter Editor to be printed in “The Lightsource,” within 30 days of the program.

  I attest that all information provided in this application is true and accurate to the best of my knowledge and that I have met eligibility criteria for this scholarship.

Status (For Board Review)

___Approved on:_________________          ___Denied on:________________________

___Letter of Approval/Denial sent to applicant on_________________________________

Signature of Board Member:_________________________________________________

Did scholarship Recipient meet Terms of Agreement?  ___Yes         ___No

Was copy of Certificate of Attendance submitted to PNWSGNA within 30 days of program date?     ____Yes    ____No

Was newsletter article submitted to PNWSGNA Newsletter Editor within 30 days of program date?   ____Yes    ____No

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