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CHRS CCC Travel Grant Application Form
1.
Please complete the following information:
First Name:
Last Name:
Title:
Institution:
City:
Province:
Email Address:
Program (if applicable):
Program Director /Supervisor (if applicable):
*
2.
Which category best describes you?
(Required.)
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)
*
3.
Please complete the following information:
(Required.)
CCC accepted abstract title:
Expected travel budget:
*
4.
Please provide a brief description of your heart rhythm/arrhythmia research:
(Required.)
*
5.
Are you receiving any other source of funding to attend the CCC?
(Required.)
Yes
No
Uncertain at this time
If 'Yes' or 'Uncertain' please specify. You must declare all other sources of funding awarded and applied for.:
*
6.
Please upload an abbreviated copy of your curriculum vitae (maximum two pages).
(Required.)
Choose File
No file chosen
*
7.
Please upload a copy of your Letter of Confirmation to present an accepted abstract at CCC.
(Required.)
Choose File
No file chosen
*
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:
(Required.)
I agree
*
9.
Date of signature:
(Required.)
Date / Time
Date
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February
March
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Click the the SUBMIT button below to finalize your travel grant application.
Questions? Contact
chrs@ccs.ca
