PNWSGNA Fall Conference Scholarship Fund

Application Form

Instructions for Application:

1. Complete the following application form (please print legibly!).
2. Attach the following to completed application form:
3. Send completed application (with attachments, if applicable) to the current PNWSGNA Scholarship Chair (contact information located on www.pnwsgna.org).

Contact Info

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?               Work      Home

Membership Info

1.      How long have you been a member of PNWSGNA? _____________________________ 2.      How long have you worked in the field of gastroenterology?  _____________________            3.      Have you received any PNWSGNA Scholarship within the past 3 years?  Yes  No 4.      If the answer to (3) was yes, list which scholarship you received along with the year that you received it: Year: _______  Scholarship: _______________________________________________ Year: _______  Scholarship: _______________________________________________ Year: _______  Scholarship: _______________________________________________

Personal Statement (Note: If you are unable to obtain other funding, Please attach a letter from your manager to verify this.)	Please write a brief description of the activity, including: Why you want to attend (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) that might bear on this application, if applicable _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________
Terms of Agreement	I understand that, if I receive a PNWSGNA Fall Conference Scholarship, I am required to submit an article to be printed in the PNWSGNA newsletter, “The Lightsource,” within 30 days following the date of the course. I agree to help out at the Fall Conference, as directed by the PNWSGNA President, and will share information from this program with my colleagues. I understand that if I do not attend the course, I will be disqualified from receiving future PNWSGNA Fall Conference Scholarships. 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.   Signature: ______________________________________________  Date: __________________
Status (Board to Complete)	Approved on: ________________ (date)        Denied on: __________________ (date)  Letter of Approval / Denial sent to applicant on ____________________________ (date)
	Did scholarship Recipient Meet Terms of Agreement?	Yes     No
	Did scholarship recipient attend the Fall Conference?	Yes     No
	Did scholarship recipient help out at the conference?	Yes     No
	Was newsletter article submitted to PNWSGNA Newsletter Editor within 30 days of conference date?	Yes     No
	Comments:     Signature of Board Member: _________________________________________ Date: ___________