APPLICATION FOR FUNDS (You may attach another page if needed )
1. BIOGRAPHICAL DATA
A. Name:
B. Address:
C. Phone:
D. E-Mail:
E. ENA Membership Number:
2. Name or Type of Activity or Project:
A. Give a brief description of the activity or project:
B. Dates of activity or project:
C. Describe how your involvement in this activity or project is related to your professional career in emergency nursing:
3. EXPENSES/RESOURCE/ FUNDS REQUESTED
A. Will your employer or other agency cover any expenses? YES NO If so, how much?
B. Other grants funding:
C. Amount of money requested from ENA:
4. DESCRIBE HOW YOUR PARTICIPATION AND ENA FINANCIAL SUPPORT OF THIS ACTIVITY WILL
BE OF BENEFIT TO OTHER MICHIGAN ENA MEMBERS:
Submit in writing to the MENA executive board c/o Gerri Muller, 13660 Nadine St., Oak Park, MI 48237 or email document to gerrimuller@prodigy.net or fax to 248.544.3448. Allow at least 60 days for processing your request.
