ANCHASL Continuing Education Award: Fall 2019 Meeting

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Please complete the following application to apply for a scholarship to attend the ANCHASL Fall 2019 Meeting, which will be held November 15, 2019 at the Campbell University School of Osteopathic Medicine in Lillington, NC. Award recipients will be required to submit a brief report on their experiences via a form.

The deadline to apply is 12 PM Eastern on October 23, 2019.

Are you currently a member of ANCHASL? *

Membership is required to be eligible for an award; however, if you are not currently a member, you may join now. ANCHASL membership information and an online application link are available here: http://www.anchasl.org/member.shtml

Yes

Joining now

What are your estimated total expenses for attending the meeting? *

Estimates may include registration, CE fees, meals, lodging, and transportation.

What is the distance (one way, in miles) that you will be traveling to attend the meeting? *

Please provide the distance from your current place of residence and the meeting.

Applicant Contact Information *

Name, Institution, Mailing Address, Telephone, Email

If you are currently employed, please describe your current position.

Institution, Start Date of Employment (Month/Year), Current Job Title

If you are a student applicant, please provide the following details about your current program of study.

School, Field of Study, Degree Pursued, Expected Date of Graduation

Please provide a brief (no more than one or two paragraphs) statement explaining how you would expect to benefit from receiving an ANCHASL Continuing Education Award. *

Attestation *

I certify that the information I have supplied on this application is true and correct to the best of my knowledge. I understand that any misrepresentation may cause denial or withdrawal of the award. I also acknowledge that ANCHASL may use my name and/or photo for publicity in relation to this award. I understand that failure to attend the meeting will require me to return the award to ANCHASL.

Required

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