Faculty of Medicine, Masaryk University in Brno



















                                      Application for Bursary
















I am hereby applying for a contribution to cover the increased expenses associated with my
participation in:





(a)

An activity assigned within the framework of study programmes



                                                                                                  *




(b)

An instruction-related activity, outside the framework of study programmes


                                                                                                  *




(c)

An activity associated with solution of project (order No.)..........

                                                                                                  *




(d)

Other activity (please specify)................................................................

                                                                                                  *

















Applicant

(surname, first/middle name, title):











(birth identification No.)










Form and year of study:










Place of work (No.:)











Title of activity:











Venue (country, town):









Date when held, duration of stay (from - to):








Means of transport:
























Amount of expenses and source of reimbursement:


























                                       All-faculty resources

                                               Other

                                           Own resources

                                             Sum total







                                               (sum)

                                               Order

                                                Sum

                                               (Sum)




Accommodation











Travelling expenses












Other .......................










...................................










Total

























Documents proving the amount of expenses


(a) are enclosed




                                                 *









(b) will be presented at Dept. of Study Affairs/Research and Development Office









    no later than (specify date) .................................

                                                 *
















Date:






Signature of applicant:































Opinion of supervisor/project co-ordinator:









































Date and signature:































Opinion of head of institution:










































Date and signature:


















Opinion of Vice-dean:




































(Note: *Strike out where not applicable).









Important notice: Please hand in your application to Dept. of Study Affairs (pregraduate students)





                           or to Research and Development Office (full-time Ph.D. students).