Event Application Form | NMSES - Nanaimo Medical Staff Engagement Society

Applicant Information

Date:
*Division/Department name:
*Lead physician:
*Email:
*Phone:

Event Information

*Event name:
*Event Date:
*Is this open to all Medical Staff? YesNo Please explain:
Not Applicable *Brief Description:
*Purpose of Event:
*Partnerships:Please list all partners involved in planning, delivery, and funding, etc.

Budget

Organizer Cost:
The Physician Lead may receive a maximum of 4 sessional hours for the planning and execution of this event at an hourly rate of $176.18/hr
Attendees will not be paid sessional time.

Please note that all sessional and reimbursement claims must be submitted within 3 months from date of occurrence.

Type	Amount
Physician Lead: Total hours: @ $176.18/hour	$
NMSES Admin Costs: @ $30.00/hour	$
Event Space Costs:	$
Catering Costs:	$
Other Costs:	$
Total requested for this Event	$

Sign and Date

Date
*The information contained in this application is true to the best of my knowledge.I agree