Financial aid application form

REQUEST FOR FINANCIAL AID FOR THE EUROPEAN PAIN FEDERATION, EFIC CONGRESS

Application Deadline: Wednesday, 15 May, 2019

Candidates presenting a poster will be highly ranked. Those from developing countries will be also be given preference, however all applications will be considered on their individual merit and reasons given. You will require support from your head of department.

Please complete this online form in full and attach two documents:
1. A clear copy of your ID, Passport or Drivers license indicating your date of birth
2. A letter signed by the head of department on the department’s letterhead confirming your status
Please note that incomplete applications will not be considered.

COUNTRY OF RESIDENCE

EMAIL *

NAME *

TITLE

ProfDrMrMs

ADDRESS DETAILS

DATE OF BIRTH * (DD.MM.YYYY)

AGE

RECOMMENDATION LETTER

COPY OF PASSPORT

PRESENT SALARY:

JOB TITLE:

ACADEMIC OR HOSPITAL INSTITUTE:

WORKPLACE ADDRESS (including department and country):

PROVIDE A SHORT DESCRIPTION OF YOUR WORK AND THE REASON WHY FINANCIAL AID IS REQUIRED:

I WILL TRAVEL ON MY OWN TO ATTEND THE MEETING:

YESNO

If no, please state name of accompanying person and relationship. i.e spouse, child, department head, etc.

ABSTRACT NUMBER & TITLE OF ABSTRACT SUBMITTED TO THE CONGRESS

NAME OF HEAD OF DEPARTMENT:

TITLE:

EMAIL ADDRESS

 

Financial support is conditional upon the recipient attending all the Congress. This will be assessed. All financial aid recipients are expected to attend the opening and closing ceremonies, and at the closing ceremonies the successful financial aid recipients will be welcomed onto the stage. Only after this will any financial reimbursement for travel be provided. No show - no reimbursement.

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