I am a Registered Nurse/Nurse Practitioner *

Registered Nurse

Nurse Practitioner

I am a financial member of NZUNS for the twelve (12) month period immediately preceding this application. *

Yes

No

I am employed in a urology focused nursing position for at least 0.5 FTE per week *

Yes

No

I acknowledge that, on completion of my study/research/course, I am required to either present a summary of learning/findings at the next NZUNS meeting, or submit a 1500-2000 word article to be published in the next NZUNS newsletter or on the NZUNS website. The article submitted to the newsletter or NZUNS website will be evidence based, appropriately referenced and demonstrates the relationship of my learning to clinical practice. *

Yes

No

Any material I publish shall acknowledge funding support of NZUNS. *

Yes

No

I have not received a financial grant from NZUNS within the last two years. *

I have

I have not

I have / I have not (select one) applied for other sources of funding. Where other sources of funding have been sought, I have specified these in the application form. *

I have applied for other sources of funding

I have not applied for other sources of funding

I agree to notify NZUNS through the NZUNS Education Team should I receive any other monies to support my proposed study/research/activity. *

I agree

If my application is successful, I understand my name, course of study and funding awarded will be released to the Award Sponsors (if applicable) and published in the NZUNS newsletter. *

I agree

Any monies received, which are not used for the purpose it was awarded, will be returned in full to NZUNS. *

I agree

The grant will be executed within one year of receipt. This includes all travel and conference attendance. *

I agree

Application Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Contact number *

(###)

###

####

Proposed commencement date *

MM

DD

YYYY

Proposed completion date *

MM

DD

YYYY

I declare the information provided in this application is true and correct

Required documents *

Please ensure you have emailed the following documents to nzuns.secretary@gmail.com

Current CV

Copy of course/program/conference outline