Nova Scotia College of Medical Laboratory Technologists

NMLW Grant Application

Applicant Information

Name of Applicant (Event Coordinator) *
Please enter your name
Current address *
Please enter your address
City *
Please enter your city
Province *
Please select your province
Postal Code (A1A 1A1) *
Please type your postal code in the following format: A1A 1A1.
Phone (123-456-7890) *
Please type your phone number in the following format: 123-456-7890
Alternate Phone (123-456-7890)
Please use the following format: 123-456-7890
Fax (123-456-7890)
Please use the following format: 123-456-7890
Email *
Please enter your email address
Alternate Email
Please enter a valid email address

Organization Information

Name of Organization *
Please enter your organization name
Current address *
Please enter your organization's address
City *
Please enter your organization's city
Province *
Please select a province
Postal Code (A1A 1A1) *
Please type your organization's postal code in the following format: A1A 1A1.
Has the organization received a NSCMLT grant in the last 3 years? *
Please tell us if your organization has received a NSCMLT grant in the last 3 years
If so provide details
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Management Sponsor

Name of Approving Management Representative *
Please enter the name of the approving management representative
Current address *
Please enter an address
City *
Please enter a city
Province *
Please select a province
Postal Code (A1A 1A1) *
Please type your postal code in the following format: A1A 1A1.
Phone (123-456-7890) *
Please use the following format: 123-456-7890
Alternate Phone (123-456-7890)
Please use the following format: 123-456-7890
Fax (123-456-7890)
Please use the following format: 123-456-7890
Email
Please enter a valid email address
Alternate Email
Please enter a valid email address

Medical Laboratory Week Event Information

Event Title *
Please enter an event title
Event Location *
Please enter an event location
Presenter *
Please enter a presenter
Event Date *
Please enter an event date

Additional Event Information

Briefly describe the event or program, including details about the instructional methods that will be used.
Please provide a description of your event
Who from your organization will participate in this event and what is the potential impact on professional development for your participants and for your organization?
Please complete this field
What are the specific objectives of the event?
Please enter the event objectives
Will you partner with any other organizations or outside agencies for funding this Event?
Please answer this question
If yes, please indicate the organization and the nature of the partnership.
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How many participants can your event accommodate?
Please enter the number of participants
How will you invite other NSCMLT members to your event?
Please tell us how you will invite others to your event

Event Budget

Expenses shall be supported with receipts when the event occurs.
Revenue
Vendor Donations
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Registration from members
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Requested NSCMLT Grant
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Total
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Expenses

Receipts
Speaker / course fee costs
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Room rental
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AV rental
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Nutrition costs (i.e. lunch break)
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Other Costs (List details and amounts)
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Total
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You must agree to this statement

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Date
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Get in Touch

380 Bedford Highway, Suite 202
Halifax, Nova Scotia B3M 2L4

Email: info@nscmlt.org

Phone: 902-453-9605

Toll Free: 888-897-4095 (NS only)

Fax: 902-454-3535