Advocacy Organization Travel Award Application

IASLC WCLC 2011 Advocacy Organization Travel Award Application

NOTE: You must have a copy of your organization's 2009 Form 990, or other government documentation ready to upload to complete this application. Company logo and headshot are optional, but preferred. The deadline to apply is Monday, March 28th at 5:00 pm, MST.
Full Organization Name
Organization Website
Full Name of Organization Representative Submitting Application

First NameLast Name
Your Title within this Organization
E-mail
Confirm E-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Day Phone Number

Area CodePhone Number
Mobile Phone Number (if different)

Area CodePhone Number
Are you the individual who would travel to Amsterdam?
If not, please name the individual who would travel on behalf of your organization here:
How did you hear about the Travel Award?
Upload web-sized Company Logo (.jpeg please, optional)

Upload a File

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Upload headshot (.jpeg please, optional)

Upload a File

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How many contacts does your organization have in your email lists (i.e. for newsletter distribution, etc.)?
How many paid staff members do you have?
How many volunteer staff members do you have?
2010 Revenue (all amounts in US Dollars):
Upload 2009 IRS Form 990 now, or you must include other government verification of non-profit status and revenue/expense :

Upload a File

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Please include your organization's mission statement here:
Are you a member of the Global Lung Cancer Coalition?
Have you worked on collaborative initiatives with IASLC in the past? (You will elaborate below.)
If you have worked with IASLC in the past, please describe those initiatives and how they were successful. If you have not worked with IASLC in the past, please describe several of your organization's most recent, major achievements (2-4 items):
Please use this area to describe the primary future initiatives of your organization (2-4 high priority items):
Please use this area to describe how your organization and IASLC could partner in the future, including specific outcomes you would aim to achieve through this partnership:
Please use this area to describe how your organization's attendance at the World Conference would benefit your organization and your efforts towards lung cancer advocacy:
Please include additional relevant information here:
Should be Empty:

IASLC WCLC 2011 Advocacy Organization Travel Award Application