CHRS Travel Grant Application Form

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* 1. Please complete the following information:

First Name:

Last Name:

Title:

Institution:

City:

Province:

Email Address:

Program (if applicable):

Program Director /Supervisor (if applicable):

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* 2. Which category best describes you?

PGY 1-3

PGY 4-6

PGY 6+ (includes fellowship)

Medical student

Graduate student (BSc, MSc)

Doctoral or Post-Doctoral

Allied Health Professional

Other (please specify)

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* 3. Please complete the following information:

Title of conference:

Date:

Location:

Abstract title:

Expected travel budget:

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* 4. Please provide a brief description of your heart rhythm/arrhythmia research:

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* 5. Are you receiving any other source of funding to attend the meeting?

Yes

Uncertain at this time

If 'Yes' or 'Uncertain' please specify. You must declare all other sources of funding awarded and applied for.:

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* 6. Please upload an abbreviated copy of your curriculum vitae (maximum two pages).

PDF, DOC, DOCX file types only.

Choose File

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* 7. Please upload a copy of your Letter of Confirmation to present accepted abstract.

PDF, DOC, DOCX file types only.

Choose File

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* 8. By checking the box below, I am giving my digital signature and verify that the information I have submitted on this form is true and accurate:

I agree

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* 9. Date of signature:

Date / Time

Date

Click the the SUBMIT button below to finalize your travel grant application.

Questions? Contact chrs@ccs.ca