THE DELPHI CENTRE Pty Ltd ACN 057 057 913 by HC120911123346

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									                                          THE DELPHI CENTRE
    Tel: +61 (03) 9482 7668   Fax: +61 (03) 9482 7669 Email: info@delphicentre.com.au   Visit: www.delphicentre.com.au
                                                    ABN 26 057 057 913


              International Conference on Trauma, Attachment & Dissociation:
                 TRANSFORMING TRAUMA, Melbourne, 12-14 Sept 2003


                                  TOTAL 4 Scholarships Offered:
          2 Pfizer and 2 Mayne Health Registration Scholarships
       CONTINUING EDUCATION SCHOLARSHIP PROGRAM -APPLICATION FORM:

       You MUST Use This Form to complete all details and mail or fax to:
Convenors - Continuing Education Scholarship Program
The Delphi Centre
Professional Development Training
PO Box 518
Carlton North 3054, Victoria, Australia.

 Name: ___________________________________________________________________________________

 Address: _________________________________________________________________________________

_________________________________________________Post code: ________________________________

 Telephone: _(_____)_______________________  Email: ________________________________________

 Occupation_______________________________________________________________________________

 Photocopy of your qualifications OR student identification: (Please enclose):

 Employer’s name: _________________________________________________________________________

           employer’s address: ________________________________________________________________

           telephone: ___________________________ - email: _____________________________________

OR name of tertiary education facility: __________________________________________________________

           address: __________________________________________________________________________

           telephone: __________________________ - email: ______________________________________

 Please outline your need for financial assistance: _________________________________________________

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 Please elaborate as to how the conference would benefit you professionally: ___________________________

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Office Use Only: 1. Postmark In / Out 2. Date rec: _____________ 3. AQ - Y, N 4. Prof / Stud 5. Iso/Tr
6. QualEnc - Y, N 7. R/10




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