Scholarship Application for Travel

Name*

LECOM Email*

Enter Email Confirm Email

Application for:*

CDCA Assisting
Dental Conference

Name of Conference*

Location of Conference*

Start Date*

End Date*

Expenses List*

Please include an itemized list below of expected expenses (flights, hotel, conference fee). Place items on the left and corresponding cost on the right.

Item	Cost

Total Cost*

Please provide the total expected cost for your trip.

Conference Topics*

Please describe the topics to be covered or focus of the conference you plan to attend.

Educational Benefit:*

Please describe the benefit this conference will bring to your personal education.

Benefit for LECOM SDM:*

Please describe the benefit this conference will bring to the school as a whole (for research, clubs, information shared, etc):

Additional Funding*

Please list any additional funding below.

Organization/Individual Providing Funding	Amount of Funding

Funds Entitlement:*

I understand that I am not entitled to any certain amount of money - any money to be allocated is given at the discretion of the SGA Executive Board.

Allocation of Funds:*

I understand that I must use the allocated money appropriately and as specified in my above itemization.

Conduct and Presentation:*

I understand I must represent L|E|C|O|M to the best of my ability and that I must present to my peers the gathered information/experiences within the academic year.

Funds Disbursement Procedure:*

I understand that I will not receive funds until I have fulfilled all requirements (receipts, presentation, no conduct violations).

School of Dental Medicine @ Bradenton Campus

Scholarship Application for Travel

Scholarship Application for Travel

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