Application for Advanced (formerly Specialist) Training Scholarship

Application for Advanced (formerly Specialist) Training Scholarship
Please provide the following information:
Name *

First Name Last Name
E-mail *
Phone *

Area Code Phone Number
Type of advanced training *
Date of advanced training *

Month Day Year
Location of advanced training *
I agree that: *

If approved, I will receive the scholarship in advance to defray training costs. I agree that the scholarship will be repaid to DCMGA if the I fail to complete all state training and volunteer requirements for certification, as well as the 2-hour DCMGA help desk commitment.
Status of application:

Approved Disapproved
Date of approval/disapproval:

Month Day Year
Date check issued:

Month Day Year
Date advanced training and volunteer requirements completed:

Month Day Year
Date help desk requirement completed:

Month Day Year
Additional comments:
Should be Empty: