TCRN Conference & Professional Development Grants 2015
Application Form
Applications close 4pm Tuesday 18th Nov 2014
For travel between 1 Jan – 30 June 2015 only.
Please read the TCRN Conference & Professional Development Grants 2015 Round 1 Guidelines while completing
this application form.
Note:
 No late applications will be accepted
 Please complete ALL relevant sections of this application and ensure that all information is correct and
complete. Proof of invitation to speak or acceptance of abstract is necessary. Incomplete or incorrect
applications WILL NOT be considered.
 Applicants whose travel plan commences in January 2015 are strongly encouraged to submit their
applications as soon as possible. These applications will be assessed as they arrive.
I am applying for (select one):
Conference grant
Professional development grant
Section 1: Applicant Details
1. First name
2. Mobile
3. Email
Surname
4. Employer
Border Medical Oncology Research Unit
Prince of Wales Hospital
St George Hospital/Sutherland Hospital
The Royal Hospital for Women
5. Profession
Administrator
Allied health professional (list):
Clinician – Researcher
Clinician – nurse
Consumer
Health Services Manager
Research Assistant
Post-doc Fellow
6. Broad
Research
Area
7. Translational
Pipeline
8. Tumour
Group Focus
The University of New South Wales
University of Technology, Sydney
Calvary Health Care
Other (list):
Senior Researcher
PhD student (Note: TCRN non-stipend
scholarship awardees are not eligible)
PhD supervisor name:
Junior medical staff (only if you are not eligible
for TESL leave)
Other (list):
Basic Science
Clinical Medicine and Science
Preventive Medicine
Health Services Research
Public Health
N/A
All
N/A
T1
T1/T2
All Cancers
Breast Cancer
Colorectal Cancer
Gynaecological Cancer
Haematological Cancer
Head and Neck Cancer
Neurological Cancer
Skin Cancer
T2
T2/T3
T3
Respiratory Cancer
Upper Gastrointestinal Cancer
Urogenital Cancer
Other (list):
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | tcrn@unsw.edu.au | www.tcrn.unsw.edu.au
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Section 2: Proposed conference/course
1. Conference/course name
2. Conference/course
city and country
3. Conference/course
venue and address
4. Conference/course date
5. Are you invited to speak?
6. Are you submitting an
abstract or a paper?
Start date:
End Date:
No (go to Q6 below)
Yes Attach a copy of the invitation to this application.
No (eligible for Professional Development grant only)
Yes → Type of presentation:
→ Abstract accepted?
Oral
Yes
Poster
No
Other:
Pending
Attach a copy of abstract and confirmation of acceptance to this application.
Section 3: Addressing the Selection Criteria
1.
Please tell us about yourself and your professional interests and experience either in cancer research or
cancer care service delivery.
Max 150 words
2.
Please provide three (3) learning objectives for the proposed conference/course and describe how achieving
these will help you excel in your current role and how this will benefit the TCRN.
Learning objectives
Benefit to your current role and the TCRN:
1.
1.
2.
2.
3.
3.
3.
Dissemination of the knowledge you will gain by undertaking this activity is very important to the TCRN.
Please indicate which of the following you are prepared to do on your return.




Present your paper or talk at a TCRN member event?
Present your paper or talk at a public forum hosted by the TCRN?
Contribute an article for the TCRN’s website?
Contribute an article for the TCRN’s newsletter, Nexus?
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | tcrn@unsw.edu.au | www.tcrn.unsw.edu.au
Yes
Yes
Yes
Yes
No
No
No
No
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Section 4: Cost Estimates
PLEASE COMPLETE ALL RELEVANT SECTIONS OF COST ESTIMATES, INCLUDING VENDOR INFORMATION.
FAILURE TO PROVIDE ALL RELEVANT INFORMATION WILL DISQUALIFY YOUR APPLICATION.
Cost
1
2
3
4
Transportation
National airfare
(economy only)
International airfare
(economy only)
Accommodation
Cost per night
# of nights
Total accommodation cost
Conference/course registration fee
Transfers (flat rate only)
National = $50
Select one
International = $100
TOTAL GRANT REQUESTED
Vendor
$
$
$
$
$
$
$
 Up to $1,000 will apply to national conference & professional development. Up to $3,000 will apply to
international conference & professional development.
 All costs must be given in Australian dollars.
 No documentation will be required at the time of application however cost estimates will be checked
to ensure they are reasonable. The TCRN reserves the right not to fully fund costs if these are deemed
to be too high.
Additional information:
5.
The TCRN understands that the total cost of travel and registration may exceed $1,000 (national) or $3,000
(international). If your total costs exceed these amounts, please indicate from where the additional funds
will be sourced, e.g. employer, personal funds, etc.
6.
If you have another funding source that is partially funding this travel, please provide the funder information
and the amount funded.
7.
I confirm that I have not received and shall not accept funding from another source that duplicates the
funding awarded by the TCRN for this conference/professional development opportunity.
(initial)
8.
I confirm that I have not received and shall not accept any funding from another Cancer Institute NSW
Translational Cancer Research Centre or Translational Cancer Research Unit.
(initial)
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | tcrn@unsw.edu.au | www.tcrn.unsw.edu.au
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Section 5: Signatures
(a) Applicant
By signing this application form I certify that all details given in this application are complete, correct and true. I
understand that the provision of false or misleading information may result in approved funding being withdrawn
or reimbursement to the TCRN being required.
Applicant Name
Signature
Date
___/___/___
(b) Employer authorisation and approval
I support the candidate’s application to attend this nominated conference/course.
Name
Title
Signature
Date
___/___/___
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | tcrn@unsw.edu.au | www.tcrn.unsw.edu.au
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