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Clinician Scientist Award Application

Prostate Cancer Canada
Clinician Scientist Award – 2010

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 MS Word or text 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: nalini.sen@prostatecancer.ca
Telephone: 416-441-2131 ext. 226
Fax: 416-441-2325
 

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1. Applicant Information (at time of application)
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2. Title of Research Project
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3. Training Information
Provide information for the Clinician-Scientist position to be funded by this award
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4. Biographical Information (optional)

Date of Birth (DD/MM/YYYY)
5. Research Address
Provide the location where the proposed research will be conducted
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Telephone: *
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Fax:
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Email: *

6. Current Email Address
Your Primary Email Address
(to be used for communications related to this award):
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7. Current Mailing Address (if different from item 5)












Telephone:
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8. Research Accounting Information
Provide information for the Financial Officer at the host institution at which this award will be held.
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Telephone: *
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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.
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Additional Undergraduate Degrees (optional):
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11. Graduate Education
Specify EACH graduate degree awarded; attach an additional page if necessary.
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Additional Graduate Degrees (optional):
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12. Post-Doctoral Training
Specify ALL post-doctoral training; attach an additional page if necessary.
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Addtional Post-Doctoral Training (optional):
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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.
Upload:

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.
Upload:

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.
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18. Reprints/Abstracts
You may append one reprint and up to three (3) abstracts.
Reprint/Abstract: *
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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.
Upload:

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.
Upload:



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


A great article by Brian Topp "Cancer's Gift"... Brian, thanks for sharing such a personal story. http://bit.ly/cHqrBL
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Prostate Cancer Canada
145 Front Street East, Suite 306, Toronto
Ontario M5A 1E3, Canada
info@prostatecancer.ca

Telephone: 416-441-2131
Toll-free: 1-888-255-0333
Fax: 416-441-2325
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