This year, the APIC DFW Board would like to select at least one chapter member to receive financial assistance (up to $800.00 per person) to apply towards the costs of attending the EPI Intensive course.  Recipient(s) of financial assistance are required to submit a written report following the program attendance.

Please complete this form and submit by the Deadline:  JULY 25, 2016.

ALL fields must be completed in order to submit the form.

Name *
Name
Phone
Phone
Will your employer provide any financial assistance for you to attend? *