Continuing Education Scholarship Application Please read the Policy & Procedure page before applying

Your name: Address: City:    State:      Zip:   Phone:   Fax:   E-mail:     Position title: Employer: Work phone       Work e-mail: Description of training/event being applied for (including date(s) & location). SAMMIE may request additional information about training/event     Projected expenses: (Complete the expense table that follows. Please include only those expenses you are seeking SAMMIE assistance with, up to the $300.00 limit. Do not include expenses that may be reimbursed by your employer or someone else. Mileage is for the use of a personal vehicle - only one person in a vehicle may request mileage.) Expense category Amount requested Registration/Tuition $ Transportation $ Lodging $ Meals $ Substitute $ Parking $ TOTAL (not over $300) $       Will your employer require that SAMMIE pay them directly for any of your scholarship award? Yes      No   Please identify which part:    Have you received a SAMMIE Scholarship in the past?   Yes      No If yes, list month and year:     Amount received $     Date submitting application: Please type your name in the box below to serve as your virtual signature: RECEIPTS AND REPORT POSTED ON SAMMIE SCHOLARSHIP RECIPIENT BLOG REQUIRED WITHIN 30 DAYS OF COMPLETION OF EVENT TO RECEIVE PAYMENT