DMCMA Tuition Assistance Application Form

Tuition Assistance Application Form

DMCMA LYNNE CAMPEAU SCHOLARSHIP FUND
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
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?*

YesNo
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

	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:*

Not received a scholarship within the past three (3) years.I have exhausted all other funding sources.
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.

(Note: Tuition Reimbursement or Verification is a separate form)
Signature of Applicant*

Clear
Date*

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

Tuition Assistance Application Form