Application for Financial Support

Your Name
Phone
Email
Address
Address Line 2
City
State
Zip

Professional Information:

Professional Status ie. 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:

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?