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Application for Financial Support
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*
are required.
Your Name
*
Phone
*
Email
*
Address
*
Address Line 2
City
*
State
*
Select…
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Rhode Island
South Carolina
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Tennessee
Texas
Utah
Vermont
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West Virginia
Wisconsin
Wyoming
Zip
*
Professional Information
Professional Status (e.g. attending physician, resident, nurse)
*
Specialty Area
*
Years Experience
*
Prior medical service experience
*
Employer / Residency Program
Employer Name
*
Employer Address
*
Employer Address Line 2
Contact Person
*
Proposed Medical Service Work
Where do you plan on traveling to?
*
Departure Date (MM/DD/YYYY)
*
Return Date (MM/DD/YYYY)
*
The type of medical services you will be providing (be as specific as possible)
*
Your medical service goals
*
Are you applying for or receiving grant funding from any other source? If so, please describe and indicate amount.
*
Sponsoring Organization
Sponsoring Organization
*
Contact Name
*
Address Line 1
*
Address Line 2
Phone # or email
*
Proposed Expenses
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?
*
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