South African Society for Basic and Clinical PharmacologyYoung Pharmacologist Travel Award

The South African Society for Basic and Clinical Pharmacology will award five students with R5,000 each to use towards the attendance of the 53rd Congress of the South African Society for Basic and Clinical Pharmacology in Pretoria, South Africa. The application deadline is 30 August 2019. Please complete the form and e-mail back to Ms Petunia Degashu (petunia.degashu@up.ac.za).

Personal detailsTitle, name and surname:Institution:Full address:Telephone number: Mobile number:E-mail address:Society membership number: Membership paid? Yes No

Abstract informationDid you submit an abstract Yes NoTitle of abstract:

FinanceDid you apply for any other funding to attend conference? Yes No If yes, what other funding did you apply for?Were you successful in the funding application? Yes No If yes, please supply amount received: RPlease specify your specific costs to attend the congress.Travel

Cost

Air ticketGround travel from and to airportOther transport

Accommodation day(s) @ R per dayRegistration feesOther (specify)Total (R)

I, ____________________________________________, declare that the above details are correct and that I comply with all the conditions related to the support by the SASBCP.

……………………………….…………. ……….……………………Applicant signature Date

……………………………….……..Supervisor name

…………………………………………………..Supervisor signature

…………………………………………………..Date