NIIC Scholarship Application

NIIC Scholarship Application

First Name*

Last Name*

Gender

Select or enter value

Degree/Credentials

Years in the Imaging Informatics Field*

Title/Role*

Department*

Organization*

Country*

Email Address*

Occupation*

Select or enter value

Occupation - Other

Medical Specialty*

Select or enter value

Medical Specialty - Other

Primary Occupation*

Select or enter value

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*

Send me a copy of my responses

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