Delha Cort Fund Application

Name of Applicant(*)

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Address:(*)

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Phone number:(*)

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Email address:(*)

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Position Held: (*)

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Amount of funding requested $(*)

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When is funding required:(*)

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Please provide proof of enrolment or proof of expenditures asking to be covered.(*)

Add another file

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Purpose of Funding Requested:

Tuition:

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Books / Software:

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Other:

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If other, please explain

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Background of Applicant in relation to the Application:

What community are you residing in?(*)

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What department are you employed in?(*)

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What school/program/training are you attending or planning to attend?(*)

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Where is the school/program/training located?(*)

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Please provide any other background information relevant to the application:

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Have you received funding from any other sources to assist you?(*)

Have you received funding from any other sources to assist you?

Yes

No

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If yes, from where?(*)

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Provide contact information for your direct Supervisor who is in support of your application:

Supervisor Name:(*)

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Supervisor Position:(*)

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Supervisor Phone Number:

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Supervisor Email: (*)

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Please describe in 500 words or less, why you should be granted funds from the Delha Cort Trust Fund and if you are granted funds, how will they be used by you?(*)

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Submit