Funding Renewal Application

Name of physician requesting funds:(Required)

First Last

Physician email address:(Required)

Name of activity/project in FEMS:(Required)

How much was the activity/project funded for last year (approximately)?(Required)

What were the outputs of the activity/project last year?(Required)

How much are you requesting for this year?(Required)

What activities will this fund (e.g., meetings, development of guidelines, data analysis)?(Required)

Approximately how many physicians will be participating?(Required)

Do you anticipate health authority involvement?(Required)

Yes

What are some intended outputs your activity/project will produce?(Required)