Health Promotion Capacity Building Support for The

Application form for Healthway

Health Promotion Capacity Building Support for the

Oceania tobacco control conference 2015

Tuesday October 20th – Thursday October 22nd 2015

perth convention and exhibition centre

Operating under the WA Tobacco Products Control Act 2006, Healthway funds health promotion projects and research, and sponsors, sport, arts and community activities which promote healthy lifestyles and environments in Western Australia.

Application form for Healthway

Health Promotion Capacity Building Support for the

OCEANIA TOBACCO CONTROL CONFERENCE 2015

Tuesday October 20th – Thursday October 22nd 2015

perth convention and exhibition centre

Please read the application guidelines before completing this form

Please do not use this form to apply for support for any other conference

Your Name______

Position/Title______

Name of your employing organisation______

(* Individuals must apply through an Incorporated Organisation)

Mailing Address______

______Postcode ______

Telephone (W) ______(H) ______Mobile ______

Name of organisation to receive funding______

Please provide your organisation’s Australian Business Number ______

Is this a GST registered organisation?YesNo

Details of Financial Institution – This allows funds to be transferred electronically to your organisation’s account

Name of Account
Name of Bank or Financial Institution
(include address)
Account Number / BSB
Number / (6 digits)

Have you submitted an abstract for theOceania Tobacco Control Conference 2015?

YesNo

If yes, please attach a copy of your abstract

Describe how attendance at the conferencewill benefit:

a)The health promotion activity/work in which you are involved

______

b)Your own personal professional development

______

How will you share information and networks gained from this professional development with colleagues and other relevant people/groups upon your return?

______

What other professional development seminars/conferences have you attended in the last two (2) years?

______

Have you received support from Healthway to attend a conference in the last 5 years?

YesNo

If yes, please state the conference andyear

______

Budget:

Please complete the following budget giving the FULL costs for each item

NOTE:Healthway will only contribute to the early registration fee of $600.

The final date for registration at the early-bird rate is 21st August 2015.

Conference Registration

$600__$600_

2. TravelState mode of transport (car/air). Please provide full details. $ Amount

______

3. Hotel Accommodation State hotel name and number of nights $ Amount

Please note that Healthway cannot cover your meal costs

______

TOTAL COSTS Total costs / $

Funding sought from Healthway $______

Funding to be contributed from other sources $______

Please statehow the additional costs will be funded (e.g. self/employer etc)

______

Please note that Healthway is generally unable to cover thefull costs of conference attendance so it is essential that you identify how the balance of your costs will be funded.

DECLARATION BY SCHOLARSHIP APPLICANT

UNDERTAKINGS AND CONDITIONS OF SCHOLARSHIP

I agree:

That no person will smoke or be seen to carry tobacco products while officially involved with this scholarship.
To acknowledge Healthway support where appropriate.
To use the scholarship for the approved purposes and for the named applicant only.
To return any unspent monies to Healthway.
To seek approval from Healthway for any changes related to the scholarship, including changes to the budget.
To provide within four weeks of the scholarship’s completion, the following:

(a)An evaluation of the project on the form provided; and

(b)A statement of income and expenditure, showing how the funds were spent, duly certified by the Scholarship Recipient.

To acknowledge the right of Healthway to terminate this agreement if the scholarship is not used according to the agreed proposal, or within the timeframes.

Agreement for issue of Recipient Created Invoices (RCTIs) as follows:

(a)Healthway can issue tax invoices in respect of the supplies where appropriate;

(b)We shall not issue tax invoices in respect of supplies where Healthway has generated a RCTI;

(c) We acknowledge that we are registered for GST at the time of entering into this agreement and will notify Healthway if we cease to be registered; and

(d)Agree to remit GST to the Australian Taxation Office on supplies that we make to

Healthway.

I confirm that my employer has in place current insurance policies for workers compensation and motor vehicle third party insurance, and that these polices will be maintained for the duration of this Agreement.

Healthway acknowledges that it is registered for GST at the time of entering this agreement and will notify your organisation if it ceases to be registered or if it ceases to satisfy any of the requirements for generating RCTIs.

DECLARATION

I declare that the information presented on this form is correct and understand if approved by Healthway, I will abide by these undertakings and conditions detailed above.

Scholarship Applicant

(print name)…………………………………………………Position…………………………………………….

Signature……………………………………………………………..Date………………………………………

Witness

(print name)…………………………………………………Position……………………………………………

Signature……………………………………………………………..Date………………………………………