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 and official letter of acceptance must be submitted to ASSTA with this application and this application must signed by the PhD Supervisor or Research Group Director.

Supervisor Declaration

I declare that the applicant satisfies all the eligibility requirements for this award and that all attachments and statements provided are true and accurate records 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:

Name:                                                              Email:

Organisation:                                                    Role: (e.g. PhD Supervisor)

 
Contact ASSTA: Either email The ASSTA Secretary, or

G.P.O. Box 143, Canberra City, ACT, 2601.

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