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ASSTA Conference Travel Awards

Application Form

Applicant Details

TITLE _____________ SURNAME _____________________________________

GIVEN NAMES _____________________________________________________

POSTAL ADDRESS___________________________________________________

_________________________________________________________________

_________________________________________________________________

TELEPHONE (____)_________________ EMAIL _________________________

ASSTA MEMBERSHIP NUMBER _______

Title of Conference: ____________________________________________

_________________________________________________________________

Date of Conference: _____________________________________________

Title of Paper accepted by Conference: __________________________

_________________________________________________________________

Authors on Paper: _______________________________________________

_________________________________________________________________

The paper was accepted based on: full paper / abstract submission

A copy of the paper/abstract must be submitted to ASSTA with this
application.

Applicant Declaration (to be completed by applicant)

I declare that the information given on this application and all attachments provided are true and accurate records and statements and I authorise ASSTA to verify any facts. I understand that if any information is found to be false this application and/or any subsequent awards may be cancelled.

Signature:

Date:
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