ISMRM Workshops
Trainee Stipend Award Claim Form

Congratulations on being awarded a stipend! Please complete the following form so that we may send your award as soon as possible. Inaccurate or incomplete information may cause a delay or failure of award transmission.

If you live in North America, we will send a check to the address you provide below.

For all other recipients, we will wire the balance directly into your bank account.

If you have any questions, please contact registrar@ismrm.org.

Section 1

Do you currently live in North America? required
Yes
No

To change your selection, please reload the page.

required
Section 2

Beneficiary Information

Please provide only the trainee's information. No funds will be mailed or wired to an institution or trainee supervisor.
Member ID Number: required
Beneficiary's Name required
First Name: Middle Initial: Family/Surname: required
Email: required
Phone: required
Beneficiary's Current Home Address
Street Address: required
Apartment/Unit Number:
City:     State/Province: Postal Code: required
Country: required
Section 3 (International)
Bank Information for Wire Payment required
Please provide the banking information of the person above.
The payment will be in your local currency; We do not wire US Dollars overseas.
Local Currency:
Name on Account:
Bank Name:
Bank Address:
Bank City:
Bank State/Province:
Bank Postal Code:
Bank Country:
IBAN Number (or Account Number for Japan & Australia):
SWIFT/BIC:
Bank Routing Number:
Receipt Uploader

Please Attach Your Receipt(s)

Upload scans or copies of any and all receipts for charges incurred involving this workshop; i.e., flight/transportation, hotel stay, meeting fees, etc.

If you have multiple receipts, please combine them into a single .zip or .pdf file. This field can only upload one file.

Please be sure the scan of your receipt is readable. Scans made using a flatbed scanner or copier are preferred.
We do not recommend using a cell phone camera to copy documents, as focus and brightness are often poor and result in illegible text.

Attach your receipt for upload:
Accepted File Types: .zip, .jpg, .png, .pdf