PRS FIT Scholarship Nomination Form

FIT Scholarship Nomination Form
FIT Full Name*

First NameLast Name(MD, DO, etc)
Program Director Full Name*

First NameLast Name(MD, DO, etc)
Fellowship Program*
i.e. Geisinger Health System Rheumatology Program
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
FIT E-mail*
Program Director Email*
Fellowship Completion Date*
(month/year - i.e. July 2020)
Membership Status of FIT Nominee*

Current PRS MemberPending Member (application already submitted)Non-Member (will submit an application)
Membership Status of Program Director*

Current PRS MemberPending Member (application already submitted)Non-Member (will submit an application)
Eligibility Certification:*

I certify that the FIT Nominee will not be double reimbursed.
Should be Empty: