Application Form
Action on Hearing Loss Conference Bursary Award
1. Applicant details
Title
First name
Surname
Email
Name
Position
Department
Institution
Address
Telephone
2. Supervisor/ Principal Investigator contact details
Name
Postal Address
Telephone
Email
3. Conference details
Conference title
Date
Reason for attendance
To present a poster
To give a talk
4. Scientific Abstract
5. How will attendance at the above conference benefit your research?
6.
Financial
request
Details
Total
(max £750)
Travel
£
Subsistence
£
Other
£
Total
*£
*Please note that it may not be possible to fund the full amount requested.
Action on Hearing Loss is the trading name of The Royal National Institute for Deaf People. A registered charity in England and
Wales (207720) and Scotland (SC038926). Registered as a charitable company limited by guarantee in England and Wales No.
454169. Registered office: 19-23 Featherstone Street, London EC1Y 8SL.
7. Are you a current Action on Hearing Loss grant-holder or student?
Yes
No
If yes, please give grant reference number:
8. Have you applied elsewhere for support to attend this conference?
Yes
No
If yes, please give details of additional support requested and when a decision is
expected:
9. Please indicate how you would like the travel award to be paid if awarded:
Personal Cheque
Payment through University/ research institute
10. Please confirm that:
a. You have read the Guidelines for Action on Hearing Loss Travel Awards.
b. Your supervisor or principal investigator has read this application and has written
a statement of support (please provide as a separate document)
c. You intend to present a poster or give a talk at the conference and your abstract
has been provided
Action on Hearing Loss is the trading name of The Royal National Institute for Deaf People. A registered charity in England and
Wales (207720) and Scotland (SC038926). Registered as a charitable company limited by guarantee in England and Wales No.
454169. Registered office: 19-23 Featherstone Street, London EC1Y 8SL.
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11. Applicant Summary CV. Do not exceed 2 pages.
Name
Current position and name of employer
Start date
Qualifications
Date
Award
Subject
Class
Awarding body
Research Experience
Dates
Appointment
Recent publications and presentations
Action on Hearing Loss is the trading name of The Royal National Institute for Deaf People. A registered charity in England and
Wales (207720) and Scotland (SC038926). Registered as a charitable company limited by guarantee in England and Wales No.
454169. Registered office: 19-23 Featherstone Street, London EC1Y 8SL.
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