Grant Application

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Name*
First Last
Address*
Street Address City State Postcode Country
Email*
Workplace*
Ward / Department*
Position*
Length of Membership*

SECTION B: Grant Application*

SECTION C: Statements Supporting Application*
Statement of the purpose for seeking grant, including the benefits that you expect to accrue to yourself and the profession from the activity. Information pertaining to what you have previously contributed to your workplace: quality, improvement, education. Include how you plan to disseminate or implement the information that you will gain from your attendance at this activity.

This statement should not exceed 300 Words.

Please state how you plan to disseminate or implement the information that you will gain from your attendance at this activity
Place to attach Additional documents*

Conference Registration Costs
Self Funded
Other Source of Funding
ACPAN Funding Sort
Travel
Self Funded
Other source of funding
ACPAN Funding Sort
Accommodation
Self Funded
Other Source of Funding
ACPAN Funding Sort
Per Diem Allowance
Self Funded
Other Source of Funding
ACPAN Funding Sort
University / College Fee
Self Funded
Other Source of Funding
ACPAN Funding Sort
Other (specify)
Self Funded
Other Source of Funding
ACPAN Funding Sort
Please specify

SECTION E: ITINERARY
Please attach receipts or a projected itinerary with approximate costing’s giving all details such as dates of travel, flight information, accommodation bookings, program of study invoice etc.

SECTION F: DECLARATION*
- If successful in this application for an education or research grant, I acknowledge that I am bound to supply a report suitable for publication in the ACPAN newsletter and or presentation at a State Seminar or National Conference. This report must be submitted within three months of the completion of the activity.