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RSTS & APHN Bursary Application Form 2021
Please fill in your details accordingly.
Full Name of Applicant
*
Email
*
APHN Membership ID
*
Title
*
Dr
Prof
Assoc Prof
Asst Prof
Mr
Mrs
Ms
Madam
Sr
Br
Gender
*
Male
Female
Profession
*
Speciality
*
Current Position/Title
*
Name of your Institution/Organisation
*
Region
*
Please indicate where you are from
No. of years working in palliative care
*
Proportion of your current working time devoted to palliative care
*
Full time (100%)
About 75% of the time
About 50% of the time
Equal to or less than 30%
Please indicate if you will be presenting a poster or oral presentation
*
Yes
No
If yes, please indicate title
List the objectives and outcomes you want to achieve by participating in this conference
*
Name of 1st Supporter:
*
Email of 1st Supporter
*
Name of 2nd Supporter:
*
Email of 2nd Supporter
*
If you have received or expect to receive funding from other sources, please specify donor and amount
Declaration
*
I declare that the information I have given in this application is true and correct.
Upload your CV
*
Upload any other supporting documents if any: (e.g. references)
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