Young Nephrology Investigators Scholarship Application Form

Young Nephrology Investigators Scholarship Application Form

Name of Applicant: _____________________________ Title: ___________________
Date of birth: ________________
Unit and Institution: _____________________________________________________
Address: ____________________________________________________________
Telephone: __________________________ Fax: ____________________________
Meeting to be attended: ________________________________________________
Organization of the Meeting: _____________________________________________
Title of the Abstract: ___________________________________________________
___________________________________________________________________
Authors of the Abstract: ________________________________________________
__________________________________________________________________

 

Status of the applicant:
Nephrology trainee / Fellow (Medical Officer, Resident, Resident Specialist) /
Nurse / Medical Technologist / Scientist / Allied Health Professional
Status of membership: Full / Associate

 

Declaration by the applicant:
I declare that I will not receive any other sponsorship for this meeting if my
application is successful.

 

Signature of Applicant:

 

 

______________________________ Date: ________________________

 

Certification by the head of the Division of Nephrology:
I declare that the above applicant is a Trainee / Fellow / Nurse / M.T. /
Scientist / Allied Health Professional * aged 40 or below on the first day of
the meeting, and I support his/her* application.

 

___________________________________ Date: ________________________
(Signature) / (Block letters)

Please submit a copy of the abstract and the letter of abstract acceptance to
Dr. Vincent CC CHOW, Membership Affairs, HKSN by email: chowcc1@ha.org.hk, fax: 25153182, or
mail C/O: Department of Medicine, Pamela Youde Nethersole Eastern Hospital, Hong Kong

*Delete where appropriate

(For Official Use)
Application Result: Approved / Not Approved. Approved amount: HK$___________