Application for Travel Scholarship - DOC

							                      Ambassador Nancy G. Brinker Award
                                 Cover Page
                                             Please type or print

               Name                                                             Email
    Mailing Address



              Phone                                                              Fax
                                                                        Amount
    Date Submitted                                                                      US$
                                                                      Requested
  Conference Name      2012 CTRC-AACR San Antonio Breast Cancer Symposium

   Dates & Location    December 4-8, 2012 San Antonio, Texas

                              Please allow 2 weeks for a decision on your application.


 How did you hear about us?       Komen web site             Other:
                                  Another organization (please specify name):
                                  Conference (please specify name):

                         Only complete applications will be accepted for review




I. Specifics of participation and benefit to the applicant




II. Statement of financial need




       5005 LBJ Freeway ● Suite 250 ● Dallas TX ● 75244 ● Tel: 972.855.1600 ● Fax: 972.701.2121
                                   E-Mail: International@komen.org
III. Detailed budget in US dollars




IV. Description of how knowledge gained at SABCS would be disseminated upon return to
Hungary




V. Did you attend the San Antonio Breast Cancer Symposium in the past? If yes, please
indicate when and in what capacity (e.g. attendee, presenter, etc.).




       5005 LBJ Freeway ● Suite 250 ● Dallas TX ● 75244 ● Tel: 972.855.1600 ● Fax: 972.701.2121
                                   E-Mail: International@komen.org