Drug and Alcohol Nurses of Australasia Inc.

Application for $2000 Professional Development Scholarship

Date: ______DANA Membership Number: ______

Name: ______

Address: ______Suburb: ______

State: ______Country:______Postcode: ______

Phone numbers: Hm: (___)______Wk: (___)______Mobile: ______

Email: ______

Current position and work location: ______

______

When did you join DANA? ______

Are you in your 3rd consecutive year of full DANA membership? □Y □ N

Have you ever previously received a DANA scholarship?□Y* □ N

* Please provide details ______

______

Please provide details about the professional development activity you intend to participate in. Include relevant dates and relevant supporting documentation.

______

How will this professional activity benefit you?

______

Will you be receiving study leave or any other funding for this activity? □Y* □ N

* Please provide details ______

______

What is the dollar value of the support you are requesting from DANA? $______

AUD or NZD? ______

The following conditions apply to DANA scholarships. Do you agree to the following conditions?

  • To provide evidence and receipts associated with the use of the scholarship within one month of the conclusion of the professional development activity. □Y □ N
  • To provide an A4 page summary and photographs about the professional development activity within one month of the event for DANA records and use in the newsletter and electronic communication. □Y □ N
  • To return to DANA in full the funds made available in the event that you are unable to attend the professional development activity. DANA would seek to receive these funds within one month of the conclusion of the planned professional development activity. □Y □ N
  • Failure of recipients to meet their obligations will result in the member being ineligible for future consideration. □Y □ N
  • Failure of recipients to meet their obligations may also result in DANA taking action to recover funds. □Y □ N

I ………………………….., confirm that the information provided is true and correct.

Signature of applicant ……………………………………………………………….

Submitting your application

On completion please submit application form and any necessary attachments to

Email: y Sunday 24th September 2017.

In the subject line of the email, use the heading ‘DANA 2017 $2000 Scholarship’.

Office Use Only:

□ Date received by DANA Scholarship Officer______

□ Date reviewed by Scholarship Review Committee______

□ Meets eligibility criteria______

□ Relevant paperwork attached______

□ Date of next Management Committee Meeting______

□ Applicant informed of outcome______

□ Payment arranged ______

□ Follow up actions noted______

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Drug and Alcohol Nurses of Australasia Inc.

PO Box 8014 Woolloongabba
Queensland Australia 4102

ABN 84 944 724112

DANA Application for $2000 Professional Development Scholarship