HeFSSA Travel Scholarship Application Portal
CONSENT: I understand the purpose for disclosing this personal information. Collection of this information complies with The Protection of Personal Information Act 4 of 2013 (POPI), South Africa. If you have any questions about the Privacy Policy contact info@hefssa.org
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Please note that consent is needed to submit this application form.
Applicant Information
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Title
First Name
Surname
E-mail Address
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example@example.com
Mobile Number
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Specialty
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Cardiologist
Paediatric Cardiologist
Cardio Thoracic Surgeon
Cardiac Physiologist
Electrophysiologist
Cardiology Fellow (Year 1)
Cardiology Fellow (Year 2)
Cardiology Fellow (Year 3)
Physician
Internal Medicine
Researcher (scientist in heart failure)
Other
Primary Hospital Affiliation
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Type N/A if not applicable.
Practice Sector
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Private Sector
Public Sector
Private & Public Sector
City
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Country
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Name, Date & Place of the Conference/Congress/Meeting
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Example: SA Heart Congress, 27 - 29 October 2024 in Sandton South Africa
Website Address for Conference/Congress/Meeting
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I am a paid-up HeFSSA member
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Yes
No
Is the congress/program/course CPD accredited?
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Yes
No
Do the academic program have a substantial focus on heart failure?
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Yes
No
I am involved in the congress as a:
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Delegate
Abstract or Case presenter
Faculty Member
Live Cases
Convener
Please give a short motivation at to why you have selected this specific program & why you would be a worthy recipient
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Support Sought for Registration Fee (in Rands)
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example: R4000 (indicate 0 if not applicable)
Support Sought for Accommodation (in Rands)
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example: R4000 (indicate 0 if not applicable)
Support Sought for Flights (in Rands)
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example: R4000 (indicate 0 if not applicable)
Support Sought for VISA-related Costs (in Rands)
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example: R4000 (indicate 0 if not applicable)
Total Scholarship Request
Minimum Amount of Funding Required (in Rands)
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example: R4000
Upload Letter of Support from HOD (If still in full-time training)
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