I certify that the information provided on this application is true and complete, and I authorize the release of the information to the Michigan Perfusion Society Scholarship Committee.

If I am selected as the scholarship recipient:

• I agree to release of my name
• Use of my Photo and or Video on the MPS website in connect with the scholarship
• Release of my biography on the MPS website in connect with the scholarship
• release of my essay on the MPS website in connect with the scholarship
• That all of the above are royalty free rights