Brisbane Convention and Exhibition Centre

2nd National Cannabis Conference

Brisbane Convention and Exhibition Centre

Wednesday 19th – Friday 21st September, 2012

Scholarship Application Form

Part A: Am I Eligible?

You must be able to tick the following criteria in order to be eligible for a scholarship:

I am based in Queensland.
My organisation is either directly or indirectly involved in the provision of support, treatment or advocacy services for young people in Queensland aged between 12-25 years.
I currently work for either a government department or an incorporated, not-for-profit community based organisation (employees or directors from private for-profit businesses, companies or enterprises are not eligible to apply).
I am not already registered to attend the 2nd National Cannabis Conference.

Part B: Applicant Details

Your First Name / Surname

Position Title

Organisation / Service Name

Postal Address Suburb Post Code

Office Phone Number Mobile Phone Number

Email Address

What is the target group of your organisation?

What geographical area do you cover?

Are You…

Full time? Part-time? Casual?

Part C: Funding Sought

Are you applying for:

A South-East Queensland Registration?

2 Scholarships available for Conference Registration fees only (NB: no travel or accommodation cost included)

A Regional, Rural and Remote Scholarship Package?

3 Scholarship Packages up to a maximumof $1,000available (NB: Funds can be used to coverregistration fees, flights andaccommodation - no meals, transfers orincidental costs included)

Part D: Applicant’s Agreement

I understand when applying for this scholarship that approval is not guaranteed. I understand that - if approved - it is my responsibility to organise my own travel and accommodation arrangements and that the reimbursement of part or all of these costs can only be made to my employer, not to me as an individual. I understand that reimbursements will only be made once receipts and an itemised Tax Invoice has been submitted by my employer to Dovetail, prior to Friday 26th October, 2012. I understand that Dovetail will only reimburse my organisation for costs agreed to in writing and I agree to contact Dovetail immediately if any changes or cancellation occurs.

I understand that my manager will be sent an email notifying them of the outcome of this application:

Manager’s Name:

Manager’s Title:

Manager’s Phone Number:

Manager’s Email Address:

Today’s Date:

Once this form is complete, please either:

1) Save this form to your computer and then send it as an attachment to

2) Fax it to us at (07) 3837 5728

3) Print out a copy and post to:

Dovetail

GPO Box 8161

Brisbane QLD 4001

For more information contact the Dovetail team on 3837 5621 or visit our website at www.dovetail.org.au

Thanks for applying and good luck! From the Dovetail Team