Australian Speech Science and Technology Association Inc.
ASSTA NEW RESEARCHER AWARD
APPLICATION FORM
1. Applicant's full name ______________________________________________________________
2. Address for correspondence:
______________________________________ Fax:_____________________________
______________________________________ Telephone:________________________
______________________________________ Email:___________________________
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3. If enrolled as a Postgraduate Student indicate:
a) Degree enrolled for _______________________________________________________
b) Institution and Department (or equivalent) _____________________________________
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c) Supervisor _________________ Supervisor's signature _____________________
d) Month and year of first degree awarded _______________________________________
4. If not enrolled in postgraduate studies, what is your highest degree?
a) Degree _________________ Month and Year awarded _________________________
b) Institution _____________________________________________________________
d) Supervisor (if applicable) _________________________________________________
5. Place of Work (if different from above): ____________________________________________
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6. Payment of travel, registration, accommodation and conference dinner:
a) Please indicate who will fund these ___________________________________________
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b) If not self, please provide signature of authorising person_ __________________________
7. Title of your paper ________________________________________________________________
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8. Names of co-authors (if applicable): __________________________________________________
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Where there are co-authors on the paper, the applicant must be the first author, and ALL authors must sign the following statement:
9. We confirm that a minimum of 80% of the submitted paper is the work of the applicant
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Applicant's Signature __________________________ Date ______________________________