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Your Name:
Your Phone Number
Your E-mail Address:
Home Address :
Rustica Membership Number:
Years of Previous Membership
Course:
Year of Study

Details of Conference/Placement (including location, rural issues, length of placement/conference, etc):

Please describe how this experience will benefit your knowledge of rural issues:

Please describe how this experience will benefit other RUSTICA members:

How have you been involved with RUSTICA previously?

How do you hope to contribute to RUSTICA in the future?

What are you hoping to gain from this experience?

Budget

 Detail (if applicable)         Cost

Registration

  

Accomodation

  

Travel

  

Miscellaneous - Please Specify

 

How much would you like to receive for this conference/placement/elective?

Alternative sources of funding sought/awarded or other scholarships that have been awarded over the course of the degree?
 

Note: If you experience any problems with this form, please contact the current scholarships representative, you should be notified electronically within 10 working days that their form has been received and is being processed.