Application Grant for a New Member Event

Application Grant for a New Member Event
The purpose of this grant is to assist in recruitment of new practicing physician members. The monies can be used for recruitment events, outreach programs, printing, speaker fees, and sponsorship of events focused on women physicians in which significant recruitment will occur or a new physician branch might be established. An physician AMWA member (national member, must be in good standing) must be one of the persons responsible for the event. You may request up to $250 per event. Application deadline is 8 weeks prior to event, but requests may be submitted up to one year in advance.

Following the event, photographs and a one page summary are required. This must be submitted, along with the event brochure, within 2 weeks of the event. Organizers must grant permission for this information to be used through AMWA media and publications.

If you have questions, contact associatedirector@amwa-doc.org.
Event Title:
Date of Event:

MonthDayYear
Date
Type of Event:
Purpose of Event:
Anticipated Number of Attendees:
Location of Event:
Amount Requested:
Responsible AMWA Member:

First NameLast Name
Role in AMWA
If Role Other, Describe:
E-mail
Phone Number

Area CodePhone Number
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agreement and Electronic Signature

By submitting this application, I affirm that the information provided is accurate and that I am an AMWA member in good standing.
Signature (Electronic)*
For Office Use Only:
AMWA Membership Confirmed:

YesNo
Grant Application Accepted:

YesNo
Reviewer:

First NameLast Name
Should be Empty:

Application Grant for a New Member Event

Agreement and Electronic Signature