Virginia Hypnosis Fund Grant Application

Basic Contact Information

First Name

Last Name

Suffix

Title

Phone

Please indicate if you are a member of ASCH

Please indicate your status

What training would these funds be applied to?

Proof of Status

This application requires proof of status. Please upload the following documents: • Graduate Students: A letter, on university letterhead from a faculty advisor stating your eligibility. • Licensed Professionals: A copy of your current license issued by the State of Virginia.

Drag & Drop Files, Choose Files to Upload

Allowed file types: .doc, .docx,.pdf, .png, .gif, .jpg

Attestation and Acknowledgements

I attest that the information provided here is truthful and accurate.

I understand that if I participate in an ASCH sponsored workshop, the registration fee will be covered with a Comp Code which will cover the full cost of the workshop.

I understand that if I participate in an ASCH approved workshop, a reimbursement, up to $500, will be made upon request and after ASCH has received the Attendee/Completion report from the Sponsor.

I understand that funds award must be used or claimed within 12 months of the award date.

Signature

Please type name for signature

Date