DIETITIANS NZ Awards

Education Trust Awards

Application Form

1Name ______

Address______

Telephone:Day______A/H ______

Mobile______Email______

2What category of membership do you hold with Dietitians NZ? ______

3Current Employer (if applicable) ______

Present Position (if applicable)______

Area of Work (e.g. foodservice management, clinical, community, public or primary health, education, industry)

______

Value of the award to the service (where not self-employed, please attach a statement of support from your employer endorsing the application)

______

4Describe your years of experience as a dietitian.Please attach a one-page CV.

iIn New Zealand

iiOverseas

5Purpose for which the award will be used. Please attach a brief description of the activity to be undertaken.

a. Conference details to be provided (if applicable)

b.Institution(s) to be visited (if applicable)

c.Other

6Budget for the project

7. Funds applied for and/or received from other sources.

8. Amount requested from the Dietitians NZ Education Trust (separate from total budget)

9Proposed dates (inclusive) of use

10Qualification (if any) to be gained

11How would this award improve your professional competenceand contribute to your professional advancement?

12Referees

You are expected to forward your referees a copy of the Referee’s Report form, asking him/her to ensure it is completed and reaches National Office by the close of business on June 1 (or the nearest following business day)

Professional referee

Name ______

Position ______

Address______

Telephone:Day______A/H ______

Mobile______Email______

Second Referee

Name ______

Position ______

Address______

Telephone:Day______A/H ______

Mobile______Email______

If successful in this application, I will in return:

1Attend the Awards Ceremony to receive the award, at my own expense. If this is not possible, I will nominate someone to accept the award on my behalf and to give an acceptance speech. (Other arrangements for the presentation of the Award may be made at the discretion of the Awards Selection Committee.)

2Write a report within two months of completing the activity and send copies to the Dietitians NZ Awards Selection Committee Convener and the News & Views editor.

I understand that if I do not meet the above conditions I will be expected to repay the award monies.

Signed ______Date ______

Checklist

1One page CV

2Brief description of the activity to be undertaken

3Employer letter of support

4Copy of the programme, if applicable, to attend the conference or course.

5Referees’ reports have been sent to Referees

6Completed application form

Submit Application

Completed application forms, supporting documentation and referee reports are to be submitted by email to National Office () by the 1st June with electronic signatures scanned or inserted. Postal applications are discouraged; please contact National Office to make arrangements for this.

Please address applications to:

National Office, Dietitians NZ

Email:

PO Box 13468, Johnsonville, Wellington 6440

Tel [04] 477 4704

Fax (04) 477 4705