EARLY CAREERS ACADEMIC GRANTS 2015

Name of Grant Holder: _____________________________________________________________

Institution of Grant Holder: __________________________________________________________
Grant Amount & Currency to be paid: _________________________________
Currency Account held in: __________________________________________
Account No: _____________________________________________________
Bank Name & Address: ____________________________________________________________
Swift Code: ______________________________________________________
IBAN (For Banks in Europe): ________________________________________________________
Please provide Swift Code as well
Intermediary Bank (Optional): _______________________________________________________
Please provide address, SWIFT Code & IBAN: __________________________________________
Date by which Grant should be Completed______________________________________________
Date by which Grant Report should be submitted ________________________________________
Name and Address of individual Responsible of Grant Administration*
On behalf of the organisation above, I confirm that I am willing to hold and administer the grant, which will
be available in its entirety to the grant holder for the purposes specified in the application.

Signed: __________________________________________________Date:___________________
Name and Position: ________________________________________________________________
DECLARATION BY THE AWARD HOLDER
I agree to use the grant in line with the purposes specified in my application, and to provide a brief (no more
than 500 words) report on its use, by the date specified above. I agree to abide by all terms and conditions
of the grant, as per the grant notification letter.

Signed: __________________________________________________ Date: __________________

(For ACU use only)
ACU Acct to be charged:
Name of person requesting payment:
Signed:

Date passed to accounts: