Prostate Cancer Canada

Clinician Scientist Award Application

Test Form

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Prostate Cancer Canada
Clinician Scientist Award – 2012

All applicants must carefully READ and FOLLOW the instructions and requirements outlined in the program guidelines and this application form.

ANY infraction of the guidelines will lead to the truncation or immediate rejection (without appeal) of the application. These regulations have the advantage of being unambiguous for applicants, easily enforceable by staff and/or review panels, and absolutely fair and equitable for all applicants.

Please note: Any documents that you upload in support of your application should be in a PDF or MS Word document.

All uploaded files should each have a unique file name and be named beginning with the applicant's name, followed by the section number. i.e. JoeSmith_14.doc

For further information contact the Prostate Cancer Canada at:
E-mail: joanne.reynolds@prostatecancer.ca
Telephone: 416-441-2131 ext.226
Fax: 416-441-2325

* - required field

1. Applicant Information (at time of application)

Last Name: *

First Name: *

Middle Name: *

Department: *

Institution: *

Citizenship: *

2. Title of Research Project

Title of Research Project: *

3. Training Information

Provide information for the Clinician-Scientist position to be funded by this award

Actual/Expected Start Date of Position to Be Funded (July 2, 2012 or later): *

Number of years of support requested (maximum two (2) years): *

Supervisor(s) Last Name: *

Supervisor(s) First Name: *

Department: *

Institution: *

4. Biographical Information (optional)

Gender:

Date of Birth (DD/MM/YYYY)

5. Research Address

Provide the location where the proposed research will be conducted

Department: *

Institution: *

Street Address (include street type, floor, room/suite numbers): *

City: *

Province: *

Postal Code: *

Telephone: *

() -

Fax:

() -

Email (this must be your own address): *

6. Current Email Address

Your Primary Email Address
(to be used for communications related to this award): *

7. Current Mailing Address (if different from item 5)

Department (if applicable):

Institution (if applicable):

City:

Province/State:

Country:

Postal Code/Zip Code:

Telephone:

() -

Fax:

() -

8. Research Accounting Information

Provide information for the Financial Officer at the host institution at which this award will be held.

Name of Financial Officer: *

Department: *

Institution: *

Street Address: *

City: *

Province: *

Country: *

Postal Code: *

Telephone: *

() -

Fax:

() -

Email: *

9. Keywords

* Provide up to six (6) keywords that describe the proposed research project.

10. Undergraduate Education

Specify EACH undergraduate degree awarded; attach an additional page if necessary.

Degree: *

Start Date (month/year): *

Date Degree Conferred (month/year): *

Institution: *

Additional Undergraduate Degrees (optional):

Upload:

11. Graduate Education

Specify EACH graduate degree awarded; attach an additional page if necessary.

Degree: *

Start Date (month/year): *

Date Degree Conferred (month/year): *

Institution: *

Supervisor: *

Additional Graduate Degrees (optional):

Upload:

12. Post-Doctoral Training

Specify ALL post-doctoral training; attach an additional page if necessary.

Start Date (month/year): *

End Date (month/year): *

Institution: *

Supervisor: *

Addtional Post-Doctoral Training (optional):

Upload:

13. Awards, Prizes, Scholarships, and Fellowships (optional)

On a separate page, list ALL awards, prizes, scholarships, and fellowships attained since the start of your undergraduate training; include the following information: Name of Award, Awarding Institution/Sponsor, State Date, End Date, Value/year; there is no limit to the number of pages you may attach.

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14. Interruptions

* Indicate periods of time greater than one month in which you were not actively engaged in research or clinical training; please also explain any career interruptions in the comment section provided.

15. Research and Clinical Training

* In a maximum of two double-spaced pages, describe your past research and clinical training. Indicate dates and names of supervisors, where applicable.

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16. Curriculum Vitae

* Provide a copy of your current C.V., including a list of ALL publications.

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17. Description of Research Project

Provide the following information on separate pages.

* Non-Scientific Summary: Using non-scientific language, provide a one page, double-spaced overview of the proposed research project. This should include a short summary of the aims of the research project, a brief overview of the current knowledge in this research area, a description of the proposed research, and a statement of the how the proposed research is consistent with the goals of the PCRFC:

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* Scientific Abstract: Provide a one-page, double-spaced summary of the proposed research, indicating the specific objectives, methodology, intended outcomes, and potential significance to prostate cancer:

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* Research Proposal: In a maximum of ten (10) double-spaced pages (including all figures), summarize the research question, the current state of knowledge in this area, the experimental approach to be taken (including methods and techniques), and the potential significance of the work to prostate cancer. References should be provided, and do not count toward the page limit. The use of appendices is not permitted:

Upload:

18. Reprints/Abstracts

You may append one reprint and up to three (3) abstracts.

Reprint/Abstract: *

Upload:

Addtional Abstracts (optional):

Upload:

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19. Letter of Support from Host Institution

* Provide a letter of support from the Dean of Faculty or Research Director confirming (a) institutional support of an appointment or pending appointment to a faculty-level clinician-scientist position, and the start date; (b) a minimum of 2.5 x 8 hour days per week, Monday to Friday, protected research time for the duration of the award; and (c) details of the appointment, including teaching load, clinical and administrative duties, laboratory/office space, start up funds, etc.

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20. Letter of Support from Research Mentor

* Provide a letter of support from a proposed research mentor, indicating the nature of the mentoring relationship that will exist between the mentor and the applicant.

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Please review your form to ensure its completion before clicking the SUBMIT button.