Student 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
I have previously applied for a student stipend:  Yes      No

 If yes, state the years you applied and if you received support:

 Have you submitted an abstract to ISMRM as the first author:  Yes      No
    If yes, indicate abstract I.D.#(s).  Please separate multiple I.D.#'s with a comma.

 Please identify your status:
PhD candidate MD clinical trainee MD/PhD trainee Postdoctoral fellow

 DO NOT release my CV to corporate sponsors

Recipients of Student Stipends will be required to submit an application for membership in the ISMRM before the funds are disbursed.
Enclosed:
 Student's Application Letter
Student's Curriculum Vitae
Abstract and confirmation of online submission
Supervisor's Letter/Eligibility Verification
Membership Application (for nonmembers only)
FOR OFFICE USE ONLY

NO.                                                                          DATE RECEIVED