4.2011 ( 1st version) 4.3.2011 ( 1st revision) 12.2015 (2nd revision )
APPLICATION FOR Scholarship / Sponsorship
7th
Event :
HKICNA International Infection Control Conference 1-3 July 2016
*Delete whichever is inappropriate (enter in block letter please)
@ for the past 36 months ( 1.1.2013 to 31.12.2015 )
Only proceed if all required information is entered.
Name : (Surname)
(Other Name)
Chinese
*(Mr./Mrs./Miss)
*Application for 1. Scholarship /
2. Sponsorship
Membership No.:
Membership Category: *Ordinary / Associate
Year joining HKICNA :
Years of Membership :
Hospital :
Department :
Post :
Telephone :
Mobile :
Email :
Correspondence Address:
Years of Service in Infection Control Team :
Years of ICLN :
Infection Control Link Nurse ( ICLN) : *Yes / No
@ Previous voluntary work / contribution to HKICNA (Please state clearly):Year Type of voluntary work / contribution, e.g. course/seminar/community program helper
@Previous sponsorship / scholarship from HKICNA to attend conference: *Yes / No
@Name of the event of the latest sponsorship /scholarship :
@Year sponsored :
For Sponsorship only –
To contribute to HKICNA if application is successful : please tick >one
no Contribution to HKICNA
tick >one
1
Member of 7 HKICNA conference support group – conference helper
2
Member of 2016 IC course support group - Site helper in 2 evenings (2.5 hours each)
3
Member of World Health carnival work group promoting hand hygiene 2016-1 day helper
th
I DECLARE that all the above information provided by me are true and correct and I further understand that
any dishonesty or false representation on this application form will lead to disqualification.
Signature of Applicant: ____________________________________________Date: ___________________
For official use only
Scholarship / Sponsorship supported: Yes/No Approved by:
Applicant to note :
Any member (Ordinary / Associate) having >3 year consecutive membership as at 31st December 2015
and fully paid-up member of 2016 is eligible to apply.
The end