Send application to CRN Chair. (Chair may request copy of program, if needed.)

Name_______________________________________

Phone: (Work)__________________ (Home)_______________

Address________________________________________________________________

Place of Employment______________________________________________________

Conference
Conference Title___________________________________

Date (Month and Year)______________________ Location_______________________

Projected Expenses
Registration: $________ Hotel: $________ Transportation: $________ Total: $_________

Amount of money requested from CRN: $_____________________

Information/Selection Criteria
How long have you been a CRN member?_________

Have you received a CE stipend from CRN within the past 3 years?_______

If so, when?_______________________

Are you presenting paper/poster session at the conference?_______

Have you applied for funding fron other sources?_______

Amount of funding from other sources expected $_________

To be completed by Chair
( ) Granted, amount $__________ To be paid after the CE program is attended.
( ) Not granted, reason:__________________________