2018 Nebraska HPV Survivor School Travel Scholarship Application

Travel Scholarship Terms & Conditions

To receive scholarship funds, applicants must be registered for the Nebraska HPV Survivor School prior to May 15, 2018.
Funds are limited and available on a first-come, first-served basis. You will be notified within 2 business days if your application has been approved.
Applicants must live at least 30 miles away from the event venue to receive mileage reimbursement. Mileage is reimbursed at 54.5 cents/mile.
Applicants must live at least 60 miles away to receive a hotel room reimbursement. Hotel is reimbursed up to $100; one night maximum.
To receive payment, applicant must complete scholarship application and provide adequate documentation/receipts for travel.
Scholarship payments will be mailed to address provided in application within two weeks of receiving documentation/receipts for travel (but not before travel has occurred).
Please email NC2 at programadmin@necancer.org with any questions.

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Hotel room reimbursement (up to $100; one night maximum)

Mileage reimbursement (54.5 cents per mile)

I have read and agree to the the terms and conditions stated at the start of this application.

Signature (please type name)