IOA Scholarship Application Form Question Title * 1. Please provide your information below: Name: * Organization: * Address 1: * Address 2: City/Town: * State/Province: ZIP/Postal Code: Country: * Email Address: * Phone Number with international codes where you may be contacted during the day: * Question Title * 2. Are you a Practicing Ombudsman? Yes No Question Title * 3. Are you an IOA member? Yes No Question Title * 4. Have you attended the IOA conference before? Yes No Question Title * 5. If Yes, were you a previous recipient of financial support from IOA? Yes No N/A If no, how did you fund your previous participation? Question Title * 6. Please explain in the space below why you believe you meet the Financial Need criteria. Please send any necessary supporting documents to info@ombudsassociation.org Question Title * 7. Please explain in the space below why your participation in the IOA conference has the potential to promote the profession in areas of the world where it is not yet developed. Question Title * 8. Have you submitted a presentation proposal or plan to be part of a panel during the conference? Yes No Question Title * 9. ESTIMATED EXPENSES: please include an approximate number for each expense: Estimated cost of round trip economy class airfare USD$ Estimated cost of hotel USD$ Estimated costs of Daily Subsistence Allowance (DSA), excluding hotel USD$ REQUEST: You can request funding for some or all of the estimated expenses either through the reimbursement of the expenses, or funding by direct payment. Question Title * 10. Please specify which expenses you would like to request funding for by checking the boxes below: Hotel DSA (daily subsistence allowance- excluding hotel) Transportation departing from indicated city: Question Title * 11. PAYMENT: Please specify how you would like to request these expenses to be paid: Reimbursement upon submission of receipts, up to the maximum approved funding amount Direct Payment of expenses to the airline, hotel, etc up to the maximum approved funding amount Question Title * 12. Please provide up to two professional references who can support your application Name Relationship Years Known City and Country Email Phone Question Title * 13. Please provide up to two professional references who can support your application Name Relationship Years Known City and Country Email Phone Question Title * 14. By typing my name below I declare that the information included is true and correct to the best of my knowledge and belief. Name Date Done