INTERNATIONAL TRANSPLANT NURSES SOCIETY
LOUISIANA CHAPTER
Grant Application to the Betty Kessler Memorial Education Fund
 
Date:_______________________,2002
 
Name:________________________________________________
 
Address: ______________________________________________
 
City: _________________________________, State:LA.,  Zip: ________________
 
Place of Employment:__________________________________________________
 
Title: (please include all credentials):________________________________________
In twenty five words or less, explain the reason for your request for grant assistance:
________________________________________________________________________
 
 
 
 
 
Assistance is for:  (Please mark all that apply)
ÿ Travel                      ÿ Registration Fees                      ÿ Accommodations
ÿ Dining                      ÿ Presentation Costs                       
ÿ Other _____________
 
The undersigned grant funds acceptor hereby agrees to the terms of acceptance:  within one calendar year of use of said funds, acceptor will reproduce his/hers presentation for educational CEU to the Local Chapter of ITNS (LA) at a scheduled educational event.  The acceptor will be responsible for the acquiring of the CEU for the event and the presentation itself.  Assistance is available from ITNS Local Chapter (LA) for the event if requested.
 
Signed:____________________________________________Date:___________,2002
For Chapter use Only:
Funds assigned/requested: $_____________.00
Approved:_____               Disapproved:______
Date:______________, 2002
Approved by:_______________________________Signature:______________________
Title:______________________________________
 
Reason for Disapproval:_____________________________________________________