Scholarship Form

Lisa M. Kolodziej Scholarship Application Form

Your Name and Title

Are You a CEDAS Member?

Yes

If No, please submit a Membership Application and evidence of processing of payment in order to be eligible for a scholarship.

Your Organization

Organization Address

Phone

CEDAS Scholarship Being Requested

(see breakdown below of costs and other sources)

Registration

Travel

Meals

Lodging

Misc.

Provide details

Total Costs (approx)

Other Funding Sources

Employer Contribution

Other

Program for which this Scholarship is being requested (include program name, dates and location):

Reason(s) For Scholarship Request: