2011 BURSARY APPLICATION FORM e

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2011 BURSARY APPLICATION FORM e Powered By Docstoc
					                                                    APPLICATION FORM

                      Canadian Diabetes Educator Certification Bursary ($450.00)

    Sponsor: NB Department of Health, Chronic Disease Prevention & Management Unit


Name of applicant:

Address:



Telephone:                                                    Alternate Telephone:

Relevancy to Current Work:

Indicate how certification as a diabetes educator is relevant to your current work and
responsibilities. (Use additional paper if required).




Please review this application with your manager or supervisor as his/her co-signature is
necessary. (Unless self-employed) Both applicant and applicant’s manager will be notified of bursary award.

Remember to include a photocopy of your certificate and original receipt from the Certification
Board.



Applicant                                                                                     Date

__________________________________________                                                    _____________________
Manager or Supervisor                                                                         Date

Please note: The personal information collected on this form is used by the Department of Health for the purpose of award and
disbursement of bursaries. All applications will be reviewed by a screening panel consisting of Department of Health employees
and representatives from the Diabetes Task Group of New Brunswick to determine eligibility for bursary. Once the bursary funds
are disbursed up to the annual limit of funding, all application forms for that fiscal year will be destroyed. Applicants may review or
correct their information by contacting the Department of Health during the fiscal year in which application is submitted. Unless self-
employed, the applicant’s Manager will also be notified of bursary award.

				
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posted:9/16/2012
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