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2017 CHRS Annual Meeting
EP and Cardiology Fellows Travel Grant Application
September 15-16, 2017
The Westin Nova Scotian, Halifax, NS
1.
Please complete the following information:
First Name:
Last Name:
Street Address:
City:
Province:
Postal Code:
Email Address:
Phone Number:
Institution:
Program:
Program Director /Supervisor:
2.
Mode of transportation to the meeting:
I will be flying to the meeting
I will be taking the train to the meeting
I will be taking the bus to the meeting
I will be driving to the meeting
*
3.
Are you a member of the CHRS?
(Required.)
Yes
No
*
4.
Will you be attending the 2017 CHRS Annual Meeting?
(Required.)
Yes
No
5.
Are you receiving any other source of funding to attend the meeting?
Yes
No
Uncertain at this time
If 'Yes' or 'Uncertain' please specify:
Proof of travel to and from the meeting will be required to receive the funds.
