Name
Address
City State ZIP
Phone Email

Professional Information:
Professional Status
Employer/Residency Program:
Name
Address
Contact person
 
Specialty area
Years experience
Prior medical service experience:
Proposed Medical Service Work:

Where do you plan on traveling to?
Sponsoring Organization
Contact name
Address
Phone # or email
 
Departure
Return
 
The type of medical services you will be providing.
Be as specific as possible.

 
Your medical service goals:
 
Are you applying or receiving grant funding from any other source? If so, please describe.

Proposed Expenses:
Please enter the number only without the dollar sign
Air Fare: $
Ground transportation: $
Housing: $
Food: $                         
How did you hear about us?
Will you be traveling with a group? If so, will any of those people also be applying for funding from the Benjamin Josephson Fund?

The Benjamin H. Josephson, MD Fund
Overlook Medical Center / Atlantic Health System
Summit, New Jersey
908-522-2853