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

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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

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Additional upload (optional)

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Additional upload 2 (optional)

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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