MDS Endorsed Meetings Application

MDS Endorsed Meeting Application
Type of Support Requested (select all that apply)
A. CONTACT INFORMATION
Title of Meeting
Organizing Body
Institution, organization or other body
Meeting Location
Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email
example@example.com
Phone Number

Country CodeArea CodePhone Number
B. EVENT INFORMATION
Meeting Website
Meeting Start Date

MonthDayYear
Start Date
Meeting End Date

MonthDayYear
End Date
Person with Fiduciary Responsibility (Name, Title)
Location where Financial Accounts are Held
Planning Committee Members
Briefly describe the meeting:
What language(s) will the meeting be presented in?
Anticipated Attendance (#)
Recommended Audience (select up to 2)

Other
Clinician - please specify:

Other
Health Professional - please specify:

Other
Upload the Event Program / Schedule containing Names of Faculty

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Please note only applications that provide complete information will be considered.
Please allow 5-7 weeks for review.
PROPOSED MDS FACULTY
- Select # of Faculty
- Name of Faculty 1
  
  First NameLast Name
- Institution
- City, Country
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Email
  example@example.com
- Is faculty an MDS Member?
- Lecture Title(s)
- Please indicate how this faculty member will be giving their lecture:
- Name of Faculty 2
  
  First NameLast Name
- Institution
- City, Country
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Email
  example@example.com
- Is faculty an MDS Member?
- Lecture Title(s)
- Please indicate how this faculty member will be giving their lecture:
- Name of Faculty 3
  
  First NameLast Name
- Institution
- City, Country
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Email
  example@example.com
- Is faculty an MDS Member?
- Lecture Title(s)
- Please indicate how this faculty member will be giving their lecture:
- Name of Faculty 4
  
  First NameLast Name
- Institution
- City, Country
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip CodeCountry
- Email
  example@example.com
- Is faculty an MDS Member?
- Lecture Title(s)
- Please indicate how this faculty member will be giving their lecture:
- Total Projected Income (USD)
  Amount in USD
- Total Projected Expenses (USD)
  Amount in USD
- Projected Gain / Loss (USD)
  To calculate: Income - (minus) Expenses = Gain / Loss
- Amount of MDS Support Requested (USD)
  Maximum support offered is $10,000 USD
- Attach a complete budget including details on the projected income and expenses. Please enter summary figures from above in the attached budget.
  
  Cancelof
- Should be Empty:

MDS Endorsed Meeting Application

A. CONTACT INFORMATION

B. EVENT INFORMATION

PROPOSED MDS FACULTY