TNS Grant Request Survey

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* 1. Full Name:

First Name:

Last Name:

Suffix:

Designation (MD, DO, etc):

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* 2. Address

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

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* 3. You are:

TNS Member
(If you are unsure if you are a member of TNS, please contact the TNS at 512.887.3875)

Neurology Resident/Fellow
(If you are unsure if you are a member of TNS, please contact the TNS at 512.887.3875)

Medical Student

Non-TNS Texas Neurologist
(Consider becoming a member of TNS. Simply join using our website at www.texasneurologist.org)

Texas Neuroscientist
(Consider becoming a member of TNS. Simply join using our website at www.texasneurologist.org)

Neurology patient care organization benefiting neurologic patients in Texas

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* 4. If you are a medical student, are you a member of SIGN?

Yes

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* 5. Are you a medical student or resident or fellow?

Yes

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* 6. If you answered "yes" to question 5, a mentor is required. Please enter the mentor's name and email address.

If "no", type NA

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* 7. Entity or Sponsoring Institution

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* 8. Project Title

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* 9. Scope of Research

Neurology Practice

Neurology Education

Neurological Disease Awareness and Prevention

Patient Support

Other

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* 10. Project Description

(Briefly describe Background, Aims, Research Plan, Future Directions)

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* 11. Budget - Upload here

Your budget, in detail, must be in a spreadsheet format with a total. Note: No additional expenses allowance

TNS Grant Request