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Bursaries for WONCA World; Prague June 2013 Application Form

Please complete in capital letters. Family Name: Given Name: Address: E Mail: Phone: Fax:

To which College / Association do you belong? Address: What is your status? Trainee / Resident Trained Family Doctor

What will be the benefit to you and / or your organisation of attendance at Wonca World 2013? (maximum 200 words)

Why do you wish to receive a Bursary? Why is other funding unavailable or inappropriate? (maximum 50 words)

If this application is successful, we agree to pay for Registration and recommended Accommodation based on appropriate original bills, to a maximum of $1,000. Signed: Name:

Position:

Date:

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