1APPLICATION FORM•Please complete the information below•Attach a Word summary of the project –maximum 1000 words•Obtain validation from a senior member of your hospital or university•Closing date is 31st October 2022ENTRANT DETAILS (please use type or block capitals)Name:...........................................................................................................................................................Date of birth:................................................................................................................................................Home address:..............................................................................................................................................Work address:...............................................................................................................................................Telephone (work):........................................................................................................................................Email:............................................................................................................................................................Job title:........................................................................................................................................................Qualifications:...............................................................................................................................................Signature:......................................................................................................................................................Date:.............................................................................................................................................................I would use my prize for: ..........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................VALIDATOR DETAILS (please use type or block capitals)Name:...........................................................................................................................................................Home address:..............................................................................................................................................Work address:...............................................................................................................................................Telephone (work):........................................................................................................................................Email:............................................................................................................................................................Job title:........................................................................................................................................................Qualifications:...............................................................................................................................................Date:.............................................................................................................................................................Iconfirm that this is the work of the entrant.................................................................................Please print off the Application Form, sign(entrant and validator), and email with your Word summary totraceymole@wfnr.co.uk or alternatively post to: WFNR Award, c/o Tracey Mole, WFNR Executive Director, 11 Rake House Farm, Rake Lane, North Shields, NE29 8EQ,UK1757_WFNR Franz Gerstenbr…ICATION_FORM_2022_AW.docx103%1 of 1
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