ABOUT YOU

 
Title*

Given Name*

Family Name*

Job Title*

Department*

Work Address*

Tel. (work)*

Tel. (mobile)

Email address*

 

YOUR APPLICATION

 
Grant Title*

Please explain what this grant will be used for.*

What will be the impact of this grant for the Hospital and its patients?*

Amount Requested (please provide a breakdown of costs, if relevant):*

Will VAT be added to this amount?*
YesNoNot Applicable

Is this the full cost of the item/service? Please also consider associated costs such as delivery and installation, where applicable.*
YesNo

[group group-full-cost]
If 'No', where will the rest of the funding come from?
[/group]

Does this grant relate to an item or items that will require on-going maintenance and/or consumables?*
YesNo

[group group-maintenance-consumables]
If 'Yes', how will these on-going requirements be funded?
[/group]

If applicable, has authorisation been given to submit this application by a senior, e.g. line manager/ward manager/supervisor?* This is necessary for education grants, as outlined in our Grants Policy
YesNo

[group group-authorisation]
If ‘Yes’, please provide the name, job title and contact details of this person.
[/group]

Please provide the date(s) of the event, course or conference, if applicable, for which financial support is being sought, and also provide any additional information to accompany your application such as a website link to the product or service for which a grant is requested.

PERSONAL DATA
The Guild is committed to protecting your privacy. Please tick the box to confirm that you consent for the Guild to process your personal data in accordance with our

Δ