APHN Bursary Application Form 2017
Important note : The successful applicants will be notified by email. The disbursement of monies by the APHN secretariat will be on a reimbursement basis on receipt of original invoices and/or receipts.
Name of Applicant
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Email
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APHN Membership ID
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Title
Gender
Profession
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Specialty
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Current Position / Title
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Institution / Organization
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Country
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No. of years working in palliative care
Your answer
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
Your answer
List the objectives and outcomes you want to achieve by participating in this conference
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Name of 1st Supporter
Your answer
1st Supporter's Email
Your answer
Name of 2nd Supporter
Your answer
2nd Supporter's Email
Your answer
Return economy air fare US$
Your answer
Accomodation
**Accommodation covers the night before the start of the conference to the night before the end of the conference
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Airport transfer (taxi/train) US$
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Total estimated cost required US$
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If you have received or expect to receive funding from other sources, please specify donor and amount:
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