Parker B. Francis Fellowship Program

FOR CURRENT
MENTORS AND
FELLOWS

>CURRENT PUBLICATIONS

>CHANGE IN STATUS

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CHANGE IN STATUS
POLICY AND PROCEDURES FOR TERMINATION AND/OR TRANSFERAL

In the event of termination, it is imperative to take the following action:

1) Write a letter addressed to:
Dr. Thomas Martin
VA Puget Sound Health Care System
1660 S. Columbian Way, 151L
Seattle, WA 98108

Dr. Martin's fax number is: 206-768-5289
Dr. Martin's e-mail address is: trmartin@u.washington.edu

2) State why the PBF Fellow wants to terminate his/her Fellowship.
(You may find that it is not necessary to terminate the Fellowship based upon Dr. Martin's understanding of the situation.)

3) Send a copy of the letter to:
Shari Hockenbery, CMP
Programs Specialist
The Francis Family Foundation
800 W. 47th St., Suite 717
Kansas City, MO 64112

Shari's fax number is: 816-531-0077
Shari's e-mail address is: shari@francisfoundation.org

In the event of a transfer request, please take the following action:

Write a letter addressed to Dr. Martin stating the reasons why the Fellow wants to transfer his/her Fellowship.
State if you will also transfer and remain the mentor.
If not, state who the proposed new mentor will be and at what institution.*
Copy Shari Hockenbery at the Francis Family Foundation.

*NOTE: If your transfer request is approved, it is important that your new information be submitted as soon as possible to both the Seattle office and the Francis Family Foundation. Please re-submit the Intent to Submit (the online form below).

INTENT TO SUBMIT FORM

CANDIDATE INFORMATION:
Full Name:
Title:
Institution:
Department:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Sponsoring Institution, Deparment, and Division/Section:
Country of Citizenship:
	US or Canadian Permanent Resident? Yes No
Total Budget Request:	Year 1: $
	Year 2: $
	Year 3: $

PRIMARY MENTOR INFORMATION:
Full Name:
Title:
Institution:
Department:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:

DEPARTMENT / DIVISION CHAIR INFORMATION:
Full Name:
Title:
Institution:
Department:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:

FISCAL OFFICER INFORMATION:
Full Name:
Title:
Institution:
Department:
Street Address:
City:
State:
Zip:
Phone:
Fax:
Email:
	Checks should be made payable to: (No checks to any individual person. Institutions, regents, trustees, departments, etc. are acceptable.)
	Full mailing address for check: