World Stroke Congress Physician Bursary Application

Fields marked * are mandatory.


Please answer the questions below in paragraph form, up to a maximum of 150 words per answer.

Please list at least one reason

Briefly explain the benefits for you, your organization and/or your colleagues. Please limit your comments to a maximum of 150 words.

Please list your full name here

Legal name of applicant as you would have it appear on a check

Please list the name and address of your organization

Name and full address of organization where applicant works

Please fill in your work phone number, including area code and any extension needed.

Usual daytime phone number, including any extension as necessary

Please supply your email address

Enter your primary email address

Please confirm your email address

Confirm your email address

Total registration amount being requested

Please list your area of practice (ie Primary Care) and anything else of relevance to this application.


Submission of Request
By clicking the box to the right, I agree to supply all original and final receipts for the funding being requested.
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This statement must be agreed to prior to submitting request


By clicking the box to the right, I acknowledge that I have read, understood, and agree to the criteria and objectives of this offer, as laid out in the CRSN World Stroke Congress Physician Bursary page.

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This statement must be agreed to prior to submitting request

In the event this application is approved, you will be contacted to supply your SIN number and mailing address.
By clicking on the SUBMIT Application button, I acknowledge that the information I have provided is complete and accurate to the best off my knowledge.

Contact us

Champlain Regional Stroke Network The Ottawa Hospital - Civic Campus Civic Parkdale Clinic, Main North 1053 Carling Avenue Ottawa, ON K1Y 4E9

Phone: 613-798-5555 x 16153
SPC Phone: 613-798-5555 x 16156