Funding Request Form

Residency Program Name

Program Director

First Last Enter Email Confirm Email

Program Coordinator

First Last Enter Email Confirm Email

Candidate

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country United States Email Candidate's Current Institution (Medical School) Date

Funding Requested In-State $250.00 Out-of-state $500.00 Please describe how the candidate’s background and/or perspective will contribute to IU School of Medicine's diversity, equity and inclusion goals. Each residency program is guaranteed funding for one candidate. Additional candidates will be funded if resources allow. Please rank candidate requests, so that Diversity Affairs can prioritize funding appropriately. * First Second Third Fourth Fifth IU School of Medicine Account Number to Receive Funds

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