the CONQUER CYSTIC Fibrosis &

Institute FOR Respiratory Health

postgraduate Research SCHOLARSHIP ProgramMe

2017application form

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INFORMATION

Please fill out the following information below:

Are you an Australian citizen? Yes/No

If No, are you an Australian permanent resident? Yes/No

I have attached a copy of my resume with this application? Yes/No

INSTITUTE FOR RESPIRATORY HEALTH MEMBERSHIP

Are you a financial member of the Institute for Respiratory Yes/No

Health?

If no click here to join before applying

QUALIFICATIONS

Please give details of your undergraduate qualifications and attach certified copies of academic transcripts:

Qualification / Level of Honours obtained if known / University / Year of study
FromTo

Please give details of your postgraduate qualifications and attach certified copies of academic transcripts:

Qualification / Research / coursework / University / Year of study
FromTo
PUBLICATIONS

Please give details of any research papers you have had published or accepted for publication.

FINANCIAL ASSISTANCE

Please give details of any other PhD awards or financial assistance you are currently receiving or have an application in progress for, including an APA scholarship.

ACADEMIC REFEREES

Please provide details of two academic referees.

Referee 1 / Referee 2
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Name
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  1. Please tell us why you are attracted to doing research and why you wish to pursue a postgraduate degree in cystic fibrosis?
  1. What do you think are potentially important areas of research in cystic fibrosis?

3.What will be your PhD project title?

4.Who will be your Project Supervisor and Co-supervisors? Please provide their emails.

5.At which University / Department will you (or have you already) enrol?

6.Have you obtained/applied for any alternative funding sources (eg NHMRC, or other supplementary scholarships from your enrolled institute)?

7.Have you discussed this project with any current clinical members of the adult CF services in WA to ensure your proposed plan is practical and feasible?

8.Please describe your PhD proposal in a separate document including

Format: Maximum 2 pages of A4 size; Minimum 2cm margins; Minimal font Times New Roman 12 (including for legends of tables/graphs). The PhD Proposal submission must be in a PDF format and not exceeding 2MB (maximum).

a)Background;

b)Research methods;

c)Anticipated results/benefit to adult CF clinical care; and

d)Time line

DECLARATION

I declare that the information supplied by me on this form and any attachments is complete, true and accurate in every particular. I acknowledge that the University I have enrolled in or the Institute for Respiratory Health may terminate any scholarship if I have misrepresented my past and/or present circumstances and that this termination may take place at any stage during my candidature. I am aware that there are severe penalties for providing false or misleading information and that I may be required to repay monies received by me to which I am not entitled.

I authorise the Institute for Respiratory Health to obtain from other educational institutions and relevant authorities at any time, details of my enrolment, academic record, examination results and bond status, including details of enrolment variations, attendance and addresses during the year, in connection with my application and with any benefits payable to me.

I authorise the release of this application and supporting documents to appropriate persons within the Institute for Respiratory Health in confidence as part of any selection process for a scholarship.

I agree to abide by the University’s and the Institute’s conditions of award and course regulations and rules as amended from time to time.

I have read and agree to the conditions of award accompanying this application.

Applicant’s Signature: Date: / / 2017

APPLICATIONS

Please send your completed application form, a copy of your current resume and a certified copy of academic records to:

Institute for Respiratory Health

Conquer Cystic Fibrosis PhD Scholarship Application

Ground Floor, E Block

Sir Charles Gairdner Hospital

Hospital Avenue

NedlandsWA 6009

Email:

Applications close 4.00pm, Friday 24th February 2017.

Emailed applications will be accepted but copies with academic records and a signed declaration must follow by mail.If further information is required, please contact us on (08) 9346 3198.