The 11th Annual Workshop on - Harvard University



Harvard T.H. Chan School of Public Health

Office of Regulatory Affairs & Research Compliance

Ethical Issues in Global Health Research

September 23-26, 2019 - Boston, MA - USA

Scholarship Application Form

Scholarships are available to a limited number of workshop attendees. Scholarships include a waiver of tuition only. Scholarship recipients are required to pay any applicable travel and lodging expenses. Those interested in applying for a scholarship must submit this form with the required materials no later than July 19th, 2019. Any attendee who is awarded a scholarship will be notified in a timely manner and asked to register on-line via a scholarship registration link provided at the time.

Send to: Alyssa Speier

( Fax: 1-617-432-2165 ( Email: aspeier@hsph.harvard.edu

Please Print/Type Clearly

Gender : □ Male □ Female

___________________________________________________________________________

Name, Degree (s)

__________________________________________________________________________

Current Job Title

___________________________________________________________________________

Organization Name

___________________________________________________________________________

Mailing Address 1

__________________________________________________________________________

Mailing Address 2

_____________________________________________________________________________________________________

City State/Province Postal Code Country

Telephone: _____________________________________ Fax: _______________________________________

(Please Include Country/City Code)

Email Address: _________________________________________________________________________

Are you a first time attendee? □yes □no

APPLICATION REQUIREMENTS

Please include the following information with this form:

▪ Resume, Bio Sketch, or Curriculum Vitae (CV)

▪ Letter of support from your home institution/company/manager

▪ In a separate document, describe how you will benefit from attending this workshop and how it relates to your current job responsibilities.

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