The Hospital Research Foundation Research Travel Awards

The Hospital Research Foundation Research Travel Awards

NALHN Application Form

1. PERSONAL INFORMATION

Name of applicant and current position:

TitleGiven namesFamily namePosition

Contact details:

Phone numberEmail address

Address:

Are you an HDR student? Yes ☐

Date of commencement of PhD/Masters: Expected completion date:

Are you a non-studentResearcher at NALHN?Yes ☐

Group and administrative department:

Have you previously been awarded a THRFResearch Travel Award in this calendar year?:Yes ☐ No ☐

Funds sought in this application: (please tick one box)

National conference☐

International conference☐

National visit to another academic institute☐

International visit to another academic institute☐

National conference and organised visit to another academic institute☐

International conference and organised visit to another academic institute☐

1. DETAILS OF CONFERENCE ATTENDANCE:

Name of Conference:

Location of Conference:

Date/s of Conference:

Have you applied for a conference travel award: Yes ☐No ☐

If no above provide a reason:

Name of academic institution for lab visit:

Name of lab and name of hosting researcher:

Location of lab:

Date/s of lab visit:

Proposed activity at the conferenceand/or hosting academic institution (including any existing collaborative links and expected outcomes).

Please indicate the career benefits of the proposed activitye.g.Chair, presentation, panel etc.

3. FINANCIAL SUPPORT FROM OTHER SOURCES (Please state amount received)

University (School/Faculty/other):

Supervisor:

External sources (Including conference travel awards):

Own funds:

Total support from other sources:

4. FINANCIAL SUPPORT REQUESTED (Please state actual costs):

$ Amount
Airfares:
Other Fares:
Conference Registration Fee (If applicable):
Visa (If applicable)
Accommodation
Funds already secured (total of question 3 above)
TOTAL (i.e. the support sought after deducting the funds already secured):

5. SIGNATURES and Statement

______

Signature of applicantPrint name of applicantDate

______

Signature of supervisorPrint name of supervisorDate

SUPERVISOR STATEMENT on expected training and career benefit of staff member/student presenting at the conference:

6. CHECKLIST

Required:

☐A completed application form.

☐Curriculum Vitae (up to 4 pages) indicating your track record (publications, abstracts, prizesand other indicators of academic achievement)

As relevant:

☐Copy of abstract showing NALHN and relevant University affiliation

☐Copy of abstract acceptance.

☐Copy of conference registration, travel itinerary

☐Copy of approved University Notification to Travel Form or NALHN Conferences and other official Travel Form.

7. SUBMISSION

Please submit final application (complete with relevant signatures and supporting papers) in one pdf file to r processing.

8. ADMINISTRATION

THRF will coordinate the assessment and review of your application, and the advice regarding the outcome of your application. Successful applicants will be reimbursed through THRF and will need to liaise with THRF’s Executive Assistant, Alexandra Brown ()

Page 1 of 6