ICSU capacity building grant for participation in pre-conference workshop to ACP2012 on Pharmacovigilance, to be held in Accra, Ghana from 9-10 July 2012

GRANT APPLICATION FORM Surname

Institution

Country

Tel. no.

First name

Educational category tick

PhD& postdoc

Highest Degree attained

Title

<5yrs post PhD

MSc

Honours

Ungdergraduate

Student no.

E-mail

Why do you wish to be considered for this sponsorship? Max. 100 words

How will you benefit from this workshop? Max. 50 words

Mention and explain one challenge this workshop will enable you address in your area of work? Max. 100 words

Kindly fill the grant application and acceptance forms and return it to [email protected] as soon as possible. DEADLINE FOR RECEIPT OF FORMS IS 28TH JUNE, 2012

ICSU capacity building grant for attendance of the pre-conference workshop to ACP2012 on Pharmacovigilance, to be held in Accra, Ghana from 9-10 July 2012

THIS GRANT ACCEPTANCE FORM IS SUBJECT TO BEING NOMINATED FOR THE ICSU SPONSORSHIP Grant Conditions: 

Applicant must be a student or researcher of any of the following categories: PhD & postdoc (formal appointment), Early career pharmacologists, max 5 years post PhD and in research-related position, Master's degree students, Honor's degree students, Undergraduate students.



Applicant must participate fully during the pre-congress Pharmacovigilance workshop.



Grant will cater for registration, research supplies, publications and documentation needed for instructional purposes.

Declaration by the Student Surname

Year of study (1st 2nd, etc.)

Initials

Institution

Called name Degree (MSc / PhD)

Country

Tel. no.

Student no.

E-mail

I have read, understand and comply with the criteria to qualify for the ICSU Training Grant.

2012(y y y y - m m – d d) Signature of Student

Date

Declaration by the Head of Department I hereby certify that the abovementioned student is registered for the indicated postgraduate degree at my institution and will benefit greatly from this workshop.

Institution

Department

Name in Print

2012(y y y y - m m – d d) Signature of Head of Department

Date

ACCEPTANCE OF CONDITIONS The Grant-holder accepts all the conditions as set out in the letter of award for an ICSU travel grant to attend the pre-conference workshop to ACP2012 on Pharmacovigilance, to be held in Accra, Ghana from 9-10 July 2012. If the grant-holder or the institution is in breach of any of the above terms and conditions, or acts contrary to any of the guidelines, or submits false information, the organizers will be entitled to cancel this agreement consider such grant monies paid out to the grant holder plus interest and legal costs immediately due and payable.

Grant-holder’s commitment Accepted and signed at ___________________on the ______day of ______________2012

__________________________________ Grant-holder (print name)

______________________ Grant-holder (signature)

___________________________________ Witness 1 (Print Name)

______________________ Witness 1 (Signature)

___________________________________ Witness 2 (Print Name)

______________________ Witness 2 (Signature)

OFFICIAL INSTITUTION STAMP

Kindly fill the grant application and acceptance forms and return it to [email protected] as soon as possible. Deadline for receipt of forms is 28th June, 2012

ONLY SUCCESSFUL APPLICANTS WILL BE CONTACTED