PRS FIT (Fellow in Training) Scholarship Nomination

Fellow Full Name*

Program Director Full Name*

Fellowship Program*

Fellowship Program end date*

Please indicate the month and year of the completion of the nominee's fellowship program

Program Address*

Please supply the mailing address of the program

FIT email*

Program Director Email*

PRS Membership Status of Nominee*

Select or enter value

PRS Membership Status of Program Director*

Select or enter value

Eligibility Certification*

I hereby certify that the nominee is currently enrolled in the Fellowship Program, and will not be reimbursed for the same expenses by the Fellowship Program.

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