NIIC Scholarship Application

First Name *

Last Name *

Gender

Degree/Credentials

Years in the Imaging Informatics Field *

Title/Role *

Department *

Organization *

Country *

Email Address *

Occupation *

Occupation - Other

Medical Specialty *

Medical Specialty - Other

Primary Occupation *

Primary Occupation - Other

Describe your interest in imaging informatics (500 words or less) *

Tell us how you intend to use this knowledge / educational opportunity (500 words or less) *

How did you hear about this opportunity? *

What support do you need to participate? *

Form Date Field *

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