RSTS & APHN Bursary Application Form 2021

Full Name of Applicant*

Email*

APHN Membership ID*

Title*

Gender*

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*

Please indicate if you will be presenting a poster or oral presentation*

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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