Word Congress of Epidemiology Bursary Application

Surname: ___________________ Other names: ___________________________________

 

Date of birth ____/ ______/ _______ Resident of: _________________________

 

Email address:

 

Telephone No:

 

Professional qualifications:

Qualification

Awarding Institution

Year awarded

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment history:

Position

Institution

Dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe current job:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I confirm that all the information given above is correct and that I will submit an abstract for presentation at the World Congress I am seeking to attend.

 

 

Signed __________________________________________________ Date _____/_____/ 20____