Name: Institution:
Student Nationality:

Degree sought and expected date of completion: Title of presentation:
Samples to be submitted for histology processing:

Authors (to be eligible, you must be first and presenting author):

Abstract (no more than 200 words):

Check where applicable. I.e., indicate the kind of presentation and if you plan to participate in the student competition. Before checking the Student Competition line, please read the competition rules and criteria.

 	Poster

 	Oral presentation

 	Student Competition

Describe how you will benefit from attending this meeting.

Total detailed travel costs:

Item	Cost (in US $)	Comments	
Travel	*	Method of travel:	
Housing		Sharing a room?	
Food			

What travel funds are available to you? Include any potential funds from advisors, department, university or other source.

Source	Amount (in US $)	Applied for or guaranteed?	
ICA 2019	Registration waiver	guaranteed	
Advisor	U$	guaranteed	

Total amount requested from Laudier Histology Travel Fund: U$
Do you need meeting registration fee waived?

 	yes

 	no

*Provide justification for waiver:

FOR STUDENTS: In a separate letter, ask your advisor to address the following questions:

Your qualifications and the quality of the research you plan to present.
Whether additional funding will be available either from your advisor or from other sources.

Note: Please make sure that your advisor submits your letter, and you submit the additional recomendation letter by the deadline, as they are a significant portion of your application score.

All material should be sent via email to: Damien Laudier no later than

September 30th,2018