<p> NORAH COOKE-HURLE TRUST (FOR THE BENEFIT OF NURSES IN SOMERSET)</p><p>Application Form</p><p>Name of applicant:</p><p>Address: Telephone number</p><p>Email address</p><p>Postcode:</p><p>Nursing / midwifery qualifications held and date achieved:</p><p>NMC PIN:</p><p>Employer:</p><p>Job Title:</p><p>Please provide a brief description of your duties in your current post:</p><p>Page 1 of 4 Please provide details of the education / training you wish to undertake:</p><p>Please describe in your own words how the education / training will help you to develop your professional knowledge and skills, and how you will convert them into practical benefits for patients through your professional practice.</p><p>Page 2 of 4 Please provide details of the full cost of the education / training*:</p><p>Description Cost (£) inc. VAT</p><p>Total Cost: *If successful, you will be required to provide proof of the costs you have declared.</p><p>Please provide details of how the full costs cost of the education / training will be met:</p><p>Funding source Proposed Contribution (£)</p><p>Applicant’s own resources:</p><p>Other sources (please specify):</p><p>Total Contributions:</p><p>Declaration</p><p>I declare that this expression of interest is made in good faith. The information contained within it is accurate and complete to the best of my knowledge and belief.</p><p>If awarded any financial assistance I undertake to use it solely for the purpose for which it is provided. If for any reason I do not undertake the education / training I have described above, I agree to return any money that has been awarded.</p><p>Signature of applicant: Date:</p><p>This form must be returned in hard copy by post* only to:</p><p>The Norah Cooke-Hurle Trust *You are advised to retain proof of posting and Somerset Community Foundation a copy of the completed application form for Yeoman House your own records. The Royal Bath & West Showground Shepton Mallet Somerset TA4 6QN</p><p>Page 3 of 4 REFERENCE</p><p>Please can you ask your line manager to complete this following section. </p><p>Name </p><p>Contact Address </p><p>Post Code:</p><p>Daytime Tel No: Mobile No: E-mail:</p><p>Relationship to Applicant</p><p>Thank you for providing the Trust with information about the applicant. We would be grateful if you could confirm that time will be made available for the applicant to complete the training and that this will be converted to benefit patients practically. All information will be treated in the strictest confidence and used for these purposes only.</p><p>Signed: Date:</p><p>Page 4 of 4</p>