Nina Scheepers
Diamantveld High School
Private Bag X6061
8300 Kimberley
Tel:
053 833 1528 (W)
Fax:
086 402 2760
E-mail: nina@amesa.org.za
APPLICATION FOR FINANCIAL SUPPORT
Note: Closing date is 30 April 2014
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I would like to apply for financial support to attend AMESA Congress 2014.
Surname:
First names:
Postal address:
Postal code:
Institution:
Tel:
Fax:
Cell:
E-mail:
Complete your congress budget:*
EXPENDITURE
Travel:
INCOME
Other sources:
Other sources:
R
Accommodation:
Registration:
Own contribution:
Amount requested from AMESA:
Other (specify) :
Other: (specify) :
Total:
Total:
I am presenting a paper at the congress: Click:
I am an AMESA member**: Click:
R
YES
NO
YES
NO
Membership number:
I undertake to write an article/report on Congress 2014 which may be published in AMESA News.
*
The application will not be considered without a detailed budget. Please indicate your own contribution.
** Preference for funding will be given to paid-up AMESA members who contribute to the congress
programme. If you are not a current member, please complete a membership application form.