APPLICATION FOR A BURSARY FOR YOUNG RESEARCHERS

Deadline for Applications is Monday31stMarch 2014

Please use font size 10-12 pt throughout. One email version sent to plus one original signed version, must be received by Lee Tomkins, Executive Director, by the closing date.

Due to the volume of applications we receive, applications which do not strictly follow the instructions in this form will be rejected

Reference No. (for office use only):
(in months) / YRB/
  1. Application Details

Applicant
Title:
Forename(s):
Surname:
Address:
Telephone:
Email:
Hospital / Institution:
Date of Birth*:
*The Applicant must be under 40 years of age at the start of the Cancun Congress (1st May 2014).
PLEASE INCLUDE A COPY OF YOUR CV AT THE END OF THIS APPLICATION FORM
  1. Research Details

Title of Research:
Details of the Hospital / Institution where research to be conducted:
Is the Research under the Supervision of a lead researcher in your department?
  1. Purpose of your Research

3.1 / Is this research an original concept or part of a follow up project?
Please give details below.
3.2 / What are the objectives of your research (this should give specific research objectives.Note: please make these objectives realistic as the research will need to address each of the objectives in turn)? Max 200 words.
3.3 / Explain how each of the objectives in 3.2 will be met. Max 800 words.

4.Financial Information (please note: the upper limit of funding is up to $20,000 per year)

Please give brief details of your expected costs:
Include details for any or all of the following: / AMOUNT
$
Equipment
Consumables
Fees
Student / secretarial support
Research personnel
Specialist help (eg Biochemist)
Preparation of Abstract
Please note: The above list is not exhaustive; please include all costs.
TOTAL
4.1 Details of any other financial assistance being requested or already obtained:

5. Please state the name of the approving ethics committee

NB: no funding will be released until an ethics committee approval has been submitted

6. Please state where you saw this Bursary advertised

7. Referees

Please provide a reference from your current supervisor (if this is provided to you as a separate letter, please copy the text into this box):
7.1 Please provide a reference from an IMS member (if this is provided to you as a separate letter, please copy the text into this box):

8.Curriculum Vitae

(Please copy your CV in to the application form in the space here (do not send a separate attachment)

9. Letter of Support

(You can paste a scan of the letter of support from the hospital / institution here, if possible)

10. Conditions

The following conditions apply:

-The research must take place before May 2016

-The applicant must be under 40 years of age at the start of the research

-References must be included within the application form

-The application should be accompanied with a letter of support from the hospital / institution where the research is to be conducted

-A typewritten report of no more than 3000 words to be submitted within 12 weeks of the completion of the research

-A summary report needs to be submitted after twelve months if research is not complete.

-Those selected may be asked to produce a poster for the 2016 World Congress. They may also be asked to present the research findings.

Signature:
Dated:

Final Checklist

Have you:

  • Completed the form in font 10-12?
  • Completed all of the sections?
  • Provided clear objectives and described how you will meet them in 3.1 and 3.2?
  • Provided text of your referenceswithin section 6?
  • Pasted your cv into section 7?
  • Pasted a scanned copy of your letter of support into section 8 or, if this is not possible, included as a separate document?