APPLICATION FORSCHOLARSHIP/ SPONSORSHIP
READ THROUGHLY the regulation and guidance and enter the form in BLOCK letter
*Delete whichever is inappropriate. Incomplete applicationform will NOT be proceeded*Type of support for application :□A. SCHOLARSHIP □B. Sponsorship
*Event for Application :30th International Congress of Chemotherapy& Infection (ICC) 24-27 Nov 2017, Taipei
Name of applicant: (Surname) (Other Name)
*(Mr./Mrs./Miss) / Chinese
Membership No.: / Membership Category: *Ordinary / Associate
Year joining HKICNA : / Years of Membership : / Years of experience at ICT :
Hospital : / Department : / Position :
Telephone : / Mobile : / Email :
Correspondence Address:
Infection Control Link Nurse ( ICLN) :*Yes / No / Years of ICLN :
Previous ( latest ) 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 course/conference: *Yes / No
Name of the latest sponsorship / Year sponsored :
Criteria for choosing A or B
A.Application for SCHOLARSHIP - Oral / poster Presentation required for successful application.
Title of poster / oral presentation to be submitted:
B.Application of sponsorship, contribution to HKICNA as follows if application is successful / tick 1
/ 2017 IC course ( Sept-Nov): Site helper in 2Thursday evening sessions (5:30pm -8pm)
/ 2017/2018 HKICNA newsletter submission of your infection control achievementabout 2 pages.
I DECLAREthat 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: ______
Eligible to apply :
Active HKICNA membership (Ordinary/Associate) for 3 or more years consecutively as of December 2016 and a fully paid-up membership for 2017 .
HKICNA – Application for Scholarship /Sponsorship 1st version 2014, 2nd version 2016