CHRS Travel Grant Application Form

A completed application includes:

completed application form,
an abbreviated copy of your curriculum vitae (maximum two pages), and
a copy of your Letter of Confirmation to present accepted abstract.

Question Title

* 1. Please complete the following information:

First Name:

Last Name:

Title:

Street Address:

City:

Province:

Postal Code:

Email Address:

Phone Number:

Institution:

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.:

Question Title

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

PDF, DOCX, DOC file types only.

Choose File

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

PDF, DOCX, DOC 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

I disagree

Question Title

* 9. Date of signature:

Date / Time

Date

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

Please make sure to review the Travel Grant Guidelines.

If you have any questions or comments, please contact the CHRS at (613) 569-3407 Ext. 418 or by E-Mail at chrs@ccs.ca.