Educational/Conference Bursary Application Form

Title *
First Name *
Last Name *
Job Title *
Dept/Directorate *
Staff Number *
Line Managers Name *
Line managers contact telephone number *
Your Email Address *
Work Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Your Telephone Number *

Title *
Venue *
Purpose(course/conference/other) *
Date of course/conference/other *
Cost applied for (up to a maximum of £400) *
Percentage to be met by SHC
Please provide details below, i.e. links to application forms, brochures, leaflets
Additional Supporting Details - Please give as much information as possible about your request and a detailed breakdown of cost ie travel, accommodation conference fees *
It is a condition of the Sussex Heart Charity that it may publicise bursaries that are made. Please confirm that this is acceptable to you. *
Confirmed
Would you be happy for us to contact you at a future date to request your help at an event?
Yes
How do you propose to recognise the support of The Sussex Heart Charity for your project? e.g. plaque, mention in newsletter, programme, press release etc. Please give details below *
If you are successful in your application, who should the cheque be made payable to? (NB This should where possible be an organisation/department/directorate, not an individual) *

Please tick to acknowledge that you have read and understood the terms of the agreement. *
Please Read: Criteria for Successful Bursary ApplicationsAgreed