ERTAC Scholarship Request - Rocky Mountain Rural Trauma Symposium

Application must be made by individual requesting to attend.

*If selected, you will be notified by email with instructions on how to proceed.

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* 1. Contact Information

Name

Facility or Agency

Profession / Discipline

City

State

Email Address

Phone Number

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* 2. In a few words, describe why you are requesting this scholarship.

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* 3. If awarded a scholarship, I agree to attend the conference and will not share the discount code provided.

Agree

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* 4. I understand that the scholarship is for registration fees only. I am responsible for all other costs associated with attending the conference.

Agree