ISMRM Workshops
Trainee Stipend Award Claim Form

Congratulations on being awarded a stipend! Please complete the following form so that we may send your award as soon as possible. Inaccurate or incomplete information may cause a delay or failure of award transmission.

If you have any questions, please contact registrar@ismrm.org

Section 1

Do you currently live in the USA? required

To change your selection, please reload the page.

Would you prefer to receive your payment via mailed check or a Corpay transfer to your bank account? required

To change your selection, please reload the page.

required
Section 2: Your Information

Member #: required

First Name:   Middle Initial:   Family/Surname: required

Email: required
Section 3: US Mailing Information

Please provide your personal mailing address. Checks will not be mailed outside of the United States.
Street Address Line 1: required
Street Address Line 2: optional
Apartment/Unit Number: optional
City:   State/Province:   Postal Code: required
Section 3: Corpay

You will receive your stipend via Corpay

ISMRM has partnered with Corpay Cross-Border Solutions to send stipend payments to awardees. Corpay has a portal called Connections that facilitates our online payments directly to your bank account.

We will use the following information to create your Corpay account, or confirm an existing account. Please whitelist/allowlist email from Corpay.com so that you receive emails from them regarding this transaction.

Bank Account Owner's Information
Account Owner's Name required
First Name:   Middle Initial:   Family/Surname:
Account Owner's Current Home Address
Street Address: required
Street Address Line 2: optional
Apartment/Unit Number: optional
City:   State/Province:   Postal Code: required
Country: required
Account Owner's Email (if different from email you entered above):
Account Owner's Phone Number: required

Bank Information for Corpay Transfer required

The payment will be in your local currency; We do not send US Dollars overseas.
Local Currency:
Bank Name:
Bank Address:
Bank City:
Bank State/Province:
Bank Postal Code:
Bank Country:

The following fields vary by country.
If you are not sure which numbers your country and bank use, please check your bank's transfer requirements to be sure.

Bank Account or IBAN Number:
SWIFT/BIC:
Bank Routing Number:

Be sure all of your bank information is included and accurate!
Any missing details will lead to delays in payment and may require you to complete this form again.

The contents of this form are securely encrypted before transmission to the ISMRM Central Office.