第32回日本摂食嚥下リハビリテーション学会学術大会 Travel Support Application Form (JSDR 32)7579

【 Travel Support Application Form (JSDR 32) 】

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Section 1. Applicant Information

※1. Full Name (as shown on passport)

※2. Affiliation / Institution

※3. Professional Title / Discipline

*Others:

※4. Email Address

Section 2. Residence and Nationality

※5. Country of Residence (at the time of application)

*Others:

※6. Nationality

*Others:

Section 3. Travel Support Category

※7. Travel Support Category

Category 1: International Presenter (Non-Japanese National) (JPY 150,000 / Applicants residing outside Japan and presenting at JSDR 32)Category 2: International Participant (Non-Japanese National) (JPY 50,000 / Presentation not required)

*Please select one category only.
Dual application or receipt of both categories is not permitted.

Section 4. Participation in JSDR 32

※8. Participation Status

PresenterParticipant (non-presenter)

Section 5. Statement of Purpose

Please briefly describe your reason for applying for Travel Support and how your participation in JSDR 32 will contribute to international and multidisciplinary exchange in dysphagia rehabilitation.

※9. Brief Statement (up to 200 words)

Section 6. Recommender Information (Optional)

*This section is optional. Please complete it only if you have a recommender.

10-1. Name of Recommender

10-2. Affiliation of Recommender

10-3. Professional Title / Position of Recommender

Section 7. Declaration and Consent

※11. Declaration

I confirm that all information provided in this application is accurate and complete.I understand that Travel Support will be provided only after confirmation of my on-site attendance at JSDR 32.I acknowledge that dual application or receipt of multiple Travel Support categories is not permitted.I agree that, in the event of false or inappropriate application, the Travel Support may be revoked and reimbursement may be required.

Section 8. Submission

By submitting this form, you agree to the terms and conditions of the JSDR 32 Travel Support Program.

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