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Student Club & Chapter Funding Request

Use this for to submit your request for student club or chapter funding!

Required fields are marked with a *.

Name of EMBS Club*:
Club Contact*:
Academic Institution (University)*:
Department*:
Mailing Address
Street Address*:
City*:
Province/State:
Postal Code/Zip:
Country*:
Telephone (incl. country code)*:
Fascimile (incl. country code):
Email*:
Attention (if necessary):

Please describe the event:

Location*:
Scheduled Date *:
Is this part of the Distinguished Lecturer Program?
Title*:
Amount Requested (US Dollars)*:
Number of Expected Attendees*:
Detailed Budget (please cut and paste into box)*:
Event Description(outline of activity, objectives, and organization. 1000 words max.)*:

Matched Funding Co-sponsors (list at least one):

Number	Amount (US Dollars)	Description
Sponsor #1 *:
Sponsor #2 :
Sponsor #3 :
Sponsor #4 :
Sponsor #5:

I understand that for this request for funding to be processed, I must submit either electronic or paper copies of letters confirming matched funds from all sponsors. Email emb-exec@ieee.org or use the executive mailing address.*

EMBS Chapter Websites:

EMBS Club Websites:

Mailing Address

Please describe the event:

Matched Funding Co-sponsors (list at least one):