Application for the 
Dr. E. Bruce Elliott Memorial Scholarship

Name_________________________________________________________________________

Professional
qualifications__________________________________________________________

Address
_______________________________________________________________________

phone
_________________________________________________________________________

fax
___________________________________________________________________________

email
_________________________________________________________________________

Do you have a current license to practice medicine in Nova Scotia?

Or, do you plan to practice in Nova Scotia? beginning when?

Have you experienced the need for this knowledge in your practice?

Do you currently have patients in your practice suspected of having EI?

Do you have the capacity in your practice to begin seeing patients suspected of having EI? 
If so, how many?

Would you like to add anything else in support of your application? (Use additional paper if desired)

After filling in the above application form, send it to:

NSAEHA 
P.O Box 31323 
Halifax, NS, B3K 5Y5