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* 1. Contact Information

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* 2. Name of Hospital Trust / CCQ that you work for

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* 3. Job Title

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* 4. How does ICHG 2019 relate to your job role?

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* 5. How will attending ICHG 2019 improve your practice?

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* 6. How will you disseminate your learning from ICHG 2019 to your colleagues and wider organisation?

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* 7. If successful in being awarded this bursary how will the remainder of your costs be met?

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