CHRS CCC 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? (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)

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3. Please complete the following information: (Required.)

CCC accepted abstract title:

Expected travel budget:

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4. Please provide a brief description of your heart rhythm/arrhythmia research: (Required.)

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5. Are you receiving any other source of funding to attend the CCC? (Required.)

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). (Required.)

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7. Please upload a copy of your Letter of Confirmation to present an accepted abstract at CCC. (Required.)

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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: (Required.)

I agree

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9. Date of signature: (Required.)

Date / Time

Date

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

Questions? Contact chrs@ccs.ca

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* 1. Please complete the following information:

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* 2. Which category best describes you? (Required.)

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* 3. Please complete the following information: (Required.)

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

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* 5. Are you receiving any other source of funding to attend the CCC? (Required.)

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

Question Title

* 7. Please upload a copy of your Letter of Confirmation to present an accepted abstract at CCC. (Required.)

Question Title

* 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.)

Question Title

* 9. Date of signature: (Required.)

1. Please complete the following information:

2. Which category best describes you? (Required.)

3. Please complete the following information: (Required.)

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.)

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

7. Please upload a copy of your Letter of Confirmation to present an accepted abstract at CCC. (Required.)

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.)

9. Date of signature: (Required.)