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Australian Speech Science and Technology Association Inc

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:___________________________

______________________________________

______________________________________

 

3. If enrolled as a Postgraduate Student indicate:

a) Degree enrolled for _______________________________________________________

b) Institution and Department (or equivalent) _____________________________________

__________________________________________________________________

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): ____________________________________________

________________________________________________________________________

________________________________________________________________________

 

6. Payment of travel, registration, accommodation and conference dinner:

a) Please indicate who will fund these ___________________________________________

___________________________________________________________________________

b) If not self, please provide signature of authorising person_ __________________________

 

7. Title of your paper ________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

 

8. Names of co-authors (if applicable): __________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

 

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

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

 

 

Applicant's Signature __________________________ Date ______________________________


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