Name: Address: Phone: Email: Health Unit or Place of Employment: Are you a member in good standing for two years prior to this application?* Yes No *Note: This will be verified Supplemental Information: In no more than 1000 words, please state your contributions to Environmental Public Health and provide details regarding the achievements you have made that would be considered and beyond” your normal “above course of work. You may provide testimonials or references in addition to your written contribution. (Please attach to application) Remittance of bursary: If selected as the recipient of this bursary, the following will be required within 30 days of attending the provincial conference: A 500 word report detailing your conference experience and learnings that will be included in the Ontario Branch News; Proof of conference registration I understand the above requirements. Name of Applicant: Signature of Applicant: Date: Please forward application to Lori Holmes, Membership Support and Engagement Councillor via email, mail or fax. Email: Mail: Lori Holmes c/o Environmental Health Department Simcoe Muskoka District Health Unit 15 Sperling Drive, Barrie ON L4M 6K9 Fax: 705-721-1495
Name: Address: Phone: Email: Health Unit or Place of Employment: Are you a member in good standing for two years prior to this application?* Yes No *Note: This will be verified Supplemental Information: In no more than 1000 words, please state your contributions to Environmental Public Health and provide details regarding the achievements you have made that would be considered “above and beyond” your normal course of work. You may provide testimonials or references in addition to your written contribution. (Please attach to application) Remittance of bursary: If selected as the recipient of this bursary, the following will be required within 30 days of attending the provincial conference: A 500 word report detailing your conference experience and learnings that will be included in the Ontario Branch News; Proof of conference registration I understand the above requirements. Name of Applicant: Signature of Applicant: Date: Please forward application to Lori Holmes, Membership Support and Engagement Councillor via email, mail or fax. Email: Mail: Lori Holmes c/o Environmental Health Department Simcoe Muskoka District Health Unit 15 Sperling Drive, Barrie ON L4M 6K9 Fax: 705-721-1495
CIPHI_ON_Provincial_Conference_Bursary_final.docx