SAMMIE CE Scholarship Application

Contact Info

Full Name: *

Street Address

Address continued

City

State

Zip

Phone #:

( )

Fax #:

( )

Email: *

Work Info

Position title: *

Employer: *

Work Phone #:

( )

Work email:

About your event

Name of training/event being applied for to include date(s) and location. SAMMIE may request additional information if needed. *

Projected Expenses:

Complete the expense table that follows. Please include only those expenses you are seeking SAMMIE assistance with, up to the $350.00 limit. Do not include expenses that may be paid to you by your employer or someone else. Mileage is for the use of a personal vehicle - only one person in a vehicle may request mileage. Scholarship reimbursement checks will be paid to YOU ONLY.

Registration/tuition:

Transportation:

Lodging:

Meals:

Substitute:

Parking:

Total (not to exceed $350):

Have you received a SAMMIE Scholarship in the past? YesNo

If yes, list month and year:

Amount received:

Date submitting application:

Please type your name in the box below to serve as your virtual signature: *

RECEIPTS AND REPORT POSTED IN SCHOLARSHIP REPORTS REQUIRED WITHIN 30 DAYS OF COMPLETION OF EVENT TO RECEIVE PAYMENT

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