Evelyn Cowell Financial Assistance Application

Applicant Details

Name

Address

Home Phone No

Work Phone No

Mobile Phone No

Email Address

Place of employment

Position

Length of time as a perioperative nurse

Length of time as a NSW OTA member

Grant Details

Conference/Seminar to be attended

Are you presenting a paper/poster?

Yes

If yes, please give details

What do you hope to gain from attending the conference/seminar? (Upload below)

Further information

Registration Costs $

Travel costs $

Have you applied for any other funds?

Yes

If yes, please provide details

Commanding officer details

Commanding officer name

Commanding officer position

Commanding officer telephone number

Additional Uploads

Upload Report

Additional upload (optional)

Additional upload 2 (optional)

I hereby submit my application for a Conference / Seminar Grant from the NSW Operating Theatre Association and agree to attend a selection interview, if required, at the designated date.

I also undertake to furnish the Association with a typewritten report for possible publication in the ACORN journal, within three months of the Conference / Seminar.

I agree