International Centre Travel Grant Application Form

Consent for storing submitted data *

Yes, I give permission to store and process my data

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Name *

Membership number *

Duration of IPEM Membership (Years) *

Must be at least one year.

Address *

Including Postcode

Telephone *

Email *

How did you hear about this grant?

The case for support (Maximum 3 x A4 pages). *

Should include: • brief details of the work of the candidate in relation to the proposed visit(s) • details of the proposed work area justifying why there is a need to bring the relevant expertise into the UK, or what the opportunities are for collaboration. • details of the centre to be visited including names and brief details of the main contacts • the proposed plan on return to the UK for taking forward the work

Funding Requirement *

Provide full details of the costs: UK Travel, Overseas Travel, Accommodation, other costs and include details of other sources of funding.

Value of grant requested from IPEM £ *

Duration of visit in days *

Refer to item 4 and 5 on the guidance notes under the heading 'application' for the attachments that are required to support the application. *