Tuesday, July 8 2008
Foundation Home About Projects Calendar News

TRAVEL GRANT SUBMISSION FORM

Important: Please read carefully. This form is only for the purpose of applying for an American Retina Foundation Travel Grant. Funds can be used for travel to a meeting or event of an educational or leadership value to the retina community and patient care. Grants will be the decision of the ARF board according to need and impact of the training. A summary report to the Foundation is required upon completion of travel. Awards can be awarded be up to $500 for airfare and up to $300 per day to offset lodging/meals and other expenses. The budget submitted must include full itinerary details and projection of expenses.

All grants must be applied for online.

First Name:
Middle Name:
Last Name:
Degree:
Organization:
YOUR Social Security#:
(9 digits only, please do not use space or -)
Address Line 1:
Address Line 2:
City: State: Zip:
(Please include 4-digit zip code extension if available eg 99999-1111)
Primary Phone:
(include extension if required)
Secondary Phone:
(include extension if required)
Fax:
Email:
Event the Grant is for:
Web Address of Event:
Budget: (Total amount you are requesting)
Breakdown:
Please use this area to
explain how the grant
will be used
(eg lodging - $200,
airfare - $300)

The American Retina Foundation
6816 Southpoint Parkway, Suite 1000
Jacksonville, FL 32216
(904) 998-0356

75.125.71.243