Cyril Tonkin fellowship application form

  • This form is applicable to permanent residents and citizens of Australia only.
  • Please print using BLOCK letters.
  • Enclose one copy application. All documents must be certified true copies or originals. The application will not be processed unless full documentation is attached.
  • Attach current curriculum vitae.
  • Failure to provide complete details or the provision of incorrect details may result in the application’s not being processed.
  • Please return completed form and attached documentationby 31st October to Angela Maplestone, Alumni and Foundation Officer, Victorian College of Pharmacy Foundation, Faculty of Pharmacy and Pharmaceutical Sciences Monash University, 381 Royal Parade, Parkville, Victoria 3052. Telephone: +61 3 9903 9087 Email:

Residency Status
Are you: An Australian citizen? 
A permanent resident of Australia? 
Have you applied for Australian permanent residence?
 Yes  No (If yes, give date of application ___/___/___)
Do you hold a current Australian Visa?
 Yes  No (If yes, please indicate Visa type: ______) (attach a copy)
Personal Details
Title / Surname / Given Names
Sex  Male  Female / Date of Birth / /
Have you changed your name since you last studied at Monash University?  Yes  No
If Yes, please provide/attach relevant documentation.
Are you a Monash staff member?  Yes  No If yes, state your staff number
Postal address for correspondence
Number and Street
Suburb / State
Country / Postcode
Phone (AH) / Phone (BH)
Mobile Number / Facsimile
Email Address
Tertiary Education Record
Degree/qualification
Year commenced / / / Year completed / / / Yearregistered / /
Additional academic information
Please provide any information on academic distinctions, prizes, occupational and research experience, publication and communications; include professional, technical or other qualifications and details of registration with professional bodies etc.
______
Work experience/relevant employment history
Duration / Employer / Position/duties
From ___/___/____ to___/___/___
dd/mm/yy dd/mm/yy
From ___/___/____ to___/___/___
dd/mm/yy dd/mm/yy
Proposed area of project
Please provide the proposed project title
Title:______
______
Referee details (include two referees)
Name and Position / Email / Contact phone number
Privacy
The information on this form is collected for the primary purpose of assessing your application for the Cyril Tonkin fellowship. Other purposes of collection include creating an enrolment record on the student database and statistical analysis. Personal information may be also disclosed to the relevant bodies for verification of your qualifications. You have a right to access personal information that MonashUniversity holds about you, subject to any exceptions in relevant legislation. If you wish to seek access to your personal information or inquire about the handling of your personal information, please contact the University Privacy Officer on 9905 6011.
Declaration and signature
I declare that I have read the instructions on this application form and that the information provided by me is true and complete. I recognise that it is my responsibility to provide all necessary documentation to support my application and I authorise MonashUniversity to obtain further relevant documentation where necessary. I acknowledge that MonashUniversity reserves the right to vary or reverse any decision regarding admission or enrolment made on the basis of incorrect or incomplete information. I accept that information provided by me will be retained by MonashUniversity. I have read the University’s statement on privacy and the purposes for which my personal information will be used (
I agree to abide by the statutes and regulations of MonashUniversity.
Applicant’s Signature ______Date ____/____/____
Attach three pages (maximum) and provide details of
  1. An abstract or summary of the proposed project
  2. A detailed statement outlining the description of the proposal
  3. A proposed schedule of activities
  4. A proposed list of budgetary requirements
  5. A personal statement - a short narrative giving a picture of yourself as an individual outlining your personal history, influences on your academic/career development, the educational and cultural opportunities to which you have been exposed, and the ways in which these experiences have affected you
  6. Expected achievements anticipated from the funding support – in particular how will the fellowship contribute towards the general goals of the project – i.e. contribution towards the practice of pharmacy/medicine use and safety in Victoria, the career development of the candidate etc
    ALSO ATTACH THE FOLLOWING
  7. Evidence of correspondence with proposed host institutions/organisations
  8. Evidence that individual organisations in Australia with a knowledge of the subject matter support the project
  9. Details of two referees

  1. Abstract or summary of the proposed project
  1. Detailed statement outlining the description of the proposal
  1. Proposed schedule of activities
  1. Proposed list of budgetary requirements
  2. Personal statement
  3. Expected achievements anticipated from the funding support

FOR USE BY FELLOWSHIP COMMITTEE ONLY
Comments on proposed project and fellowship eligibility
Please comment on the viability of the proposed project especially in relation to outcomes and fellowship eligibility
Approval by fellowship committee (or nominee): / I certify that the committee is satisfied that the applicant has sufficient background and experience undertake the proposed project. The research proposal is viable and that the applicant will be a worthy recipient of the Cyril Tonkin fellowship.
Signature: ______
Date: ______

The Victorian College of Pharmacy Foundation

Faculty of Pharmacy and Pharmaceutical Sciences
Monash University [Parkville Campus]

381 Royal Parade, Parkville, VIC 3052, Australia

Telephone +61 3 9903 9635 Facsimile +61 3 9903 9581
Email

ABN 12 377 614 012 CRICOS provider number 00008C