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O’Brien Institute Postdoctoral Scholarship
Funding Application Form
Submit form by email to [email protected] as a single PDF file. The information on this Personal Data form will be for internal
use ONLY.
CANDIDATE CONTACT DETAILS
APPLICATION TYPE
Name:
CSM Postdoctoral Scholarship (2 Year)
Phone:
CSM Postdoctoral Scholarship Extension (1 Year)
SUPERVISOR(S) CONTACT DETAILS
Name:
Phone:
E-mail:
Funding is contingent on successful applicants’ ability to seek
Tri-Council scholarship funding. Are you aware of any
restrictions on your ability to apply for Tri-Council funding
(e.g., time since degree completion, citizenship)?
Yes :
Dept hosting trainee:
No:
If yes, please explain: :
Name:
Phone:
E-mail:
SIGNATURES
The undersigned agree to, and accept, the general conditions governing any award made pursuant to the sponsorship of this
application as set out in the relevant Cumming School of Medicine Terms of Reference.
Print Name
Supervisor
Co-Supervisor:
Applicant:
Signature
Date
CANDIDATE NAME:
PROJECT TITLE
PROGRAM
Anticipated start date of training program (MM/YY):
Anticipated completion date of training program (MM/YY):
Proposed starting date for award (MM/DD/YY):
Other information (eg. Reason for 1 year Award application):
EXTERNAL FUNDING INFORMATION
Other granting agency(ies) to which a similar application has been or will be submitted
Granting Agency(ies) / Application Date(s):
ACADEMIC INTERRUPTION
Indicate the period, reasons for the interruption, or experiences gained that are relevant to your future studies and intended career
path:
CANDIDATE NAME:
ACADEMIC RECORD
ACADEMIC BACKGROUND OF APPLICANT
Degree/Diploma/Specialization/Faculty
University/Institution/Country
Dates of Enrolment
FROM (MM/YY)
TO (MM/YY)
UNIVERSITY ACADEMIC ACHIEVEMENTS (Prizes, Honors, Awards, Scholarships) (Use additional pages if necessary.)
Prizes/Honors/Awards
Awarded By
Year Won/Held
CANDIDATE NAME:
RESEARCH EXPERIENCE / ACADEMIC RECORD
RESEARCH AND OTHER RELEVANT WORK EXPERIENCE OF APPLICANT
FROM:
(MM/YY)
TO:
(MM/YY)
Position
Institution/Company/City/Country
Supervisor’s Name
CANDIDATE PUBLICATIONS Append a list of your scientific publications to this page. Include peer-reviewed
manuscripts, reviews, and abstracts/ presentations under separate headings. List papers/reviews that have been
published or accepted for publication, and abstracts/presentations at significant scientific meetings. Submitted
manuscripts require a dated copy of the Editors’ notice of receipt of the manuscript for review.
Peer-reviewed manuscripts published
Manuscripts submitted
Abstracts and presentations
Invited reviews or book chapters Published or In Press
LETTERS OF REFERENCE/SUPPORT
Identify two individuals in addition to the proposed supervisor(s) who have been asked to submit a letter of reference on your
behalf. The letter from the proposed supervisor(s) should provide details and rationale for selecting and proposing the candidate
for support.
Name
(Proposed Supervisor)
Institution/Organization
Email Address
University of Calgary
Letters of reference should be submitted by e-mail directly to [email protected] .
Letters should highlight the candidate’s strengths as they relate to suitability/experience in research (e.g. originality,
technical ability, demonstrated skills, judgment, critical skills, etc.) and the benefit that the proposed experience would
provide the applicant toward their career goals. The letter from the proposed supervisor must provide a commitment
to the required annual support ($25,000 salary + Plan C benefits) for the duration of the award, and all other conditions
detailed in the CSM Terms of Reference.
CANDIDATE NAME:
APPLICANT’S ACCOMPLISHMENTS
Outline any relevant academic, leadership, work and/or research accomplishments and/or experiences that have contributed to your
career development to date. Contributions described in this section may include academic, non-academic, and research achievements.
Provide background information on major scholarships or awards and their significance. Do not exceed the space below.
CANDIDATE NAME:
SUPERVISOR’S RESEARCH TRACK RECORD
(If co-supervision, provide information for each supervisor)
SUPERVISOR RESEARCH PUBLICATIONS – On a separate page, list your publications for the past 5 years. Only list
papers published or accepted for publication. Only list Abstracts that include trainees under your direct supervision.
Underline the names of graduate level trainees and Postdoctoral Scholars.
TRAINING ENVIRONMENT
Supervisor’s Name:
Faculty Rank:
Starting date of Faculty Position:
SUPERVISOR’S RESEARCH FUNDING
List active research grants and only the portion of the funding you receive. Do not list equipment or equipment maintenance grants
or research allowances associated with studentship or fellowship awards. (Use additional pages if necessary.)
Currently Active Grants
Granting Agency
Role
(PI/Co-PI)
Title of Project
Period of
Support
Amount/Year
Role
(PI/Co-PI)
Title of Project
Period of
Support
Amount/Year
Active
Pending
Granting Agency
CANDIDATE NAME:
SUPERVISOR’S RESEARCH TRAINEES List all trainees over the past 5 years (In program or completed)
Surname, Initial(s)
Program
(MSc, PhD,
PDF, etc.)
Source of Support
Personal Awards
Supervisor’s
(please specify)
Grants
Date of Training
From
To
(MM/YY)
(MM/YY)
#Pubs in Program
Papers
Abstracts
CANDIDATE NAME:
SUPERVISOR TO DISCUSS TRAINING ENVIRONMENT AND ROLE OF TRAINEE IN PROPOSED RESEARCH PROJECT.
Describe in specific detail the resources available to support the applicant’s research and the broad training opportunities the
environment provides. Outline the benefit for the applicant in this environment, highlighting the facilities and other personnel with
which the trainee will have the opportunity to interact. Detail the role of the trainee in the proposed research project and how it
links to the supervisor’s research program and/or research group. (Do not exceed space allocated here.)
CANDIDATE NAME:
PROPOSED RESEARCH PROJECT
In the space provided below provide a summary of the research project to be undertaken. The research plan outlining the project
should state the specific objectives, the methodological approach, and the defined key milestones or deliverables to be achieved.
(Do not exceed space allocated here.)