DMCMA Scholarship

Scholarship - Request

DMCMA LYNNE CAMPEAU SCHOLARSHIP FUND
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Court
Current Position
Years of Service in Current Position
Years of Service in WA Court System
Are you a current DMCMA member in good standing?
If you answered NO above, who is the DMCMA member endorsing you?
This must be someone who works with you at court court and who is also a member in good standing.
Course Information
Provider of Course
Title of Course
Location of the Course (City/State)
Dates of Course
Estimated Cost

Rows	Amount ($)
Tutition:
Registration/Conference Fee:
Lodging:
Travel/Mileage ($.67):
Per Diem:
Other:

Total Estimated Amount ($):
Please attach a class description and/or brochure)

Cancelof
TOTAL FUNDS REQUESTED FROM DMCMA ($):
CANNOT EXCEED: $500 FOR MEMBERS $250 FOR NON-MEMBERS
How does this content of this course relate to your current responsibilities in the court system?
If you have changed job assignments or responsibilities in the last two year, please describe:
What is the benefit to the court system if you participate in this program?
Other comments or information pertinent to this application (optional):
I certify that I have:
By signing and submittng this application I agree to submit for reimbursement within 30 days following the education attended and to provide a written report indicating the benefit of the education by submitting the form below:

Scholarship - Reimbursement Request or Verification of Attendance Form
Signature of Applicant
Date

MonthDayYear
Date
Once submitted form will be forwarded for Approval.
Treasurer
Should be Empty:

Scholarship - Request