New Entrant
Stipend Check Sheet

 Complete, print, and include this Check Sheet with your stipend materials.
Family Name  
First/Given   Middle initial  
Degree 
Institution
Institution Address
City 
State/Province Postal Code/Zip+4 
Country
Contact Phone Home Phone
Email
Supervisor
Recipients of student stipends will be required to submit an application for membership in the ISMRM before the funds are disbursed.
Enclosed:
 New Entrant's Application Letter
 New Entrant's Curriculum Vitae
 Department Chair's Letter
 Eligibility Verification
 Membership Application (for nonmembers only)
FOR OFFICE USE ONLY

NO. DATE RECEIVED