MAMSS BARBARA YATES EDUCATIONAL GRANT APPLICATION FORM  (Please print or type)  NAME_______________________________________________________________________ INSTITUTION _______________________________________________________________ ADDRESS___________________________________________________________________ TELEPHONE #: _________________________   FAX #: ____________________________

YES            NO

1.         I am currently employed as a medical staff services professional       ___(Yes)            ___(No)             If yes:              I have been employed as a MSSP for ________ years                                     My title is __________________________________ 2.         I am an Active member in good standing of the MAMSS                 ___(Yes)            ___(No) 3.         I am requesting financial support for the following purpose.  Please include specific              information, cost and timetables (use an additional page if necessary):               ____________________________________________________________________________               ____________________________________________________________________________               ____________________________________________________________________________   4.         For information only: I am a member in good standing of the National Association                   ___(Yes)            ___(No)             Medical Staff Services    5.         I am currently active in MAMSS at the local chapter or state level        ___(Yes)       ___(No)             If yes, please list your positions:             ____________________________________________________   6.         I am currently receiving other financial aid or grants                        ___(Yes)          ___(No) If yes, please explain: __________________________________      7.         When was the last time you attended a conference or seminar? __________________ 8.         Name of your immediate supervisor:______________________________________ I hereby request consideration for the Barbara Yates Educational Grant offered by MAMSS.  I have attached my personal statement to assist the MAMSS Board in arriving at a decision.  I attest that all information submitted is true and factual and was written by me.  Signature__________________________________              Date______________________