Hardship fund to support SOM membership

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* 1. Full name

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* 2. Member since

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* 3. Membership renewal date (month and year)*

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* 4. Email

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* 5. Are you currently employed?*

Yes

No

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* 6. Current employer (If unemployed type N/A)

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* 7. Assistance requested from employer?

Yes

No

N/A (not currently employed)

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* 8. Reason for partial or denial of assistance by employer? (If unemployed type N/A)

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* 9. Date of assistance request (month and year)

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* 10. Reason for request/financial hardship?
To consider your request, the SOM hardship committee needs to understand what is unique about your situation that supports your request, including the reason for your request, the nature of your financial hardship, any alternative avenues used to acquire the funds requested and why you believe that you are deserving of such an award. The more detail you can provide, the easier it is for the committee to make a reasonable determination. Please keep text under 500 words.