TNS Grant Request TNS Grant Request Questions? Contact the TNS office at 512.887-3875 or send an email to ky@cameroAMS.com OK Question Title * 1. Full Name: First Name: Last Name: Suffix: Designation (MD, DO, etc): OK Question Title * 2. Address Address * Address 2 City/Town * State/Province * ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 3. You are: TNS Member(If you are unsure if you are a member of TNS, please contact the TNS at 512.887.3875) Neurology Resident/Fellow(If you are unsure if you are a member of TNS, please contact the TNS at 512.887.3875) Medical Student Non-TNS Texas Neurologist(Consider becoming a member of TNS. Simply join using our website at www.texasneurologist.org) Texas Neuroscientist(Consider becoming a member of TNS. Simply join using our website at www.texasneurologist.org) Neurology patient care organization benefiting neurologic patients in Texas OK Question Title * 4. If you are a medical student, are you a member of SIGN? Yes No OK Question Title * 5. Are you a medical student or resident or fellow? Yes No OK Question Title * 6. If you answered "yes" to question 5, a mentor is required. Please enter the mentor's name and email address. If "no", type NA OK Question Title * 7. Entity or Sponsoring Institution OK Question Title * 8. Project Title OK Question Title * 9. Scope of Research Neurology Practice Neurology Education Neurological Disease Awareness and Prevention Patient Support Other OK Question Title * 10. Project Description(Briefly describe Background, Aims, Research Plan, Future Directions) OK Question Title * 11. Budget - Upload here Your budget, in detail, must be in a spreadsheet format with a total. Note: No additional expenses allowance PDF, DOC, DOCX file types only. Choose File Choose File No file chosen Remove File Your budget, in detail, must be in a spreadsheet format with a total. Note: No additional expenses allowance OK Question Title * 12. Do you have additional funding for this project? Yes No OK Question Title * 13. References(Limit is 10) OK DONE