Stipend Application Form
PVD Council Fellows in Training Workshop
Saturday, November 3, 2012
8:00 am – 5:00 pm
Los Angeles Convention Center, Los Angeles, CA
Name
Degree
Professional Title _______________________ __________________________
Department/Division
University/Hospital/Institution
Street Address
City
State
Telephone
Zip Code
Fax
Email Address
Candidate Requirements
Consideration for selection requires:
1. A complete and signed application form.
2. A brief letter of nomination from a sponsor within the candidate’s institution who is familiar with the candidate’s experience
and interests.
3. A brief letter prepared by the candidate indicating the basis for his or her interest in the workshop.
4. The candidate’s curriculum vitae.
Upon acceptance of the application, a $750 travel stipend will be approved for attendees outside the local area. Travel Stipends are
intended to assist the attendee with their travel and hotel expenses. The participant incurs all other incidental expenses.
Yes, my sponsor letter is included.
Yes, my letter indicating the basis of my interest in the Seminar is included.
Yes, a copy of my curriculum vitae is included.
I understand that there is a limited amount of funding for support available and that applications are considered on a first come, first served
basis
Signature
Date
(electronic signature accepted)
Applications must be submitted electronically. Download and complete the form and submit it along with accompanying documents to
viola.gold@heart.org by 5:00 pm CT Friday, October 5, 2012.