2014 Postdoctoral Fellowship Application

2014 Postdoctoral Fellowship Application

How to Complete this Application

To navigate through this application, use your “TAB” key to get to the next “enter text here” field. For check boxes, please place your cursor over the box that applies, and select by clicking the box once. All instructional information is in italics.

NOTE: Some “enter text here” fields have character length limitations. If you find that you can no longer type, a message might appear that you have reached the limitation. Press “TAB” to go to the next cell in the application.

NEW / RENEWAL

This application is: (Place an “x” by hand)

APPLICANT

Family Name: enter text here / Given Name(s): enter text here
Mailing Address: enter text here / Permanent Address: enter text here
Telephone (Home): enter text here / Telephone (Business): enter text here
Fax: enter text here / Email: enter text here
Yes / No

Citizenship:CanadianCheck one by hand

If other, specify:enter text here

Yes / No

If other, are you a Canadian Landed Immigrant?

If yes, give effective date and attach copy of visa: enter text here (year/month/day)

PROJECT

A Canadian Blood Services Postdoctoral Fellowship (CBS-PDF) is sought under the direction of enter text here who is affiliated with Canadian Blood Services as enter text here

Start date: enter start date hereNo. of years: enter number of years here

Title of Project: enter text here

If a stipend, bursary or subsidy has been or will be sought from other agencies, programs or foundations, specify souce and amount(s) requested: enter text here

AGREEMENT

Does funding constitute potential conflict of interest?

Yes / No

The undersigned agree that general conditions governing the award of a CBS-PDF, as set out in the Guidelines are accepted by the applicant and supervisor.

Signature: ______

ApplicantSupervisorR&D Director

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

ACKNOWLEDGEMENT

This will acknowledge receipt of your application for a CBS Postdoctoral Fellowship.

Acknowledgement to be sent to:

(Enter applicant’s name and mailing address)

Family Name: enter text here / Mailing Address: enter text here
Given Name(s): enter text here / Telephone: enter text here
Fax: enter text here / Email: enter text here

Additional information required immediately in support of this application is:

(To be completed by Centre for Innovation, CBS)

This information should be forwarded by express mail within seven (7) days of receipt of this acknowledgement to:

Manager, Centre for Innovation

Canadian Blood Services

1800 Alta Vista Drive

Ottawa, Ontario

K1G 4J5

Tel: 613-739-2408

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

A.APPLICANT INFORMATION

(i)Education

Degrees obtained or expected / Institution / Specific Field / Dates Attended
From / To
enter text here / enter text here / enter text here / enter start date / enter end date
enter text here / enter text here / enter text here / enter start date / enter end date
enter text here / enter text here / enter text here / enter start date / enter end date
enter text here / enter text here / enter text here / enter start date / enter end date
enter text here / enter text here / enter text here / enter start date / enter end date

(ii)Title of Research Thesis

enter text here

(iii)Brief Summary of Research Thesis (limited to 23 lines of text).

enter text here

(No attachments to this page.)Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

B:RESEARCH TRAINING

Dates / Institution / Department / Supervisor
From / To
enter start date / enter end date / enter text here / enter text here / enter text here
enter start date / enter end date / enter text here / enter text here / enter text here
enter start date / enter end date / enter text here / enter text here / enter text here
enter start date / enter end date / enter text here / enter text here / enter text here

C:PROFESSIONAL EXPERIENCE

D:OTHER RELEVEANT WORK EXPERIENCE

E.AWARDS / GRANTS / SCHOLARSHIPS HELD

Fill in details of all post-secondary personnel awards, grants or scholarships held.

Funding Agency / Type of Grant / Awarded
From / Awarded
To / Amount / Centre
enter text here / enter text here / enter start date / enter end date / $ amount / enter Centre
enter text here / enter text here / enter start date / enter end date / $ amount / enter Centre
enter text here / enter text here / enter start date / enter end date / $ amount / enter Centre
enter text here / enter text here / enter start date / enter end date / $ amount / enter Centre

F:PUBLICATIONS AND PRESENTATIONS

(Include authors, title, year, journal, volume, pages)

(i)List peer-reviewed publications. (Attach if published, submitted or in preparation.)

enter text here

(ii)List other publications. (Attach if published, submitted or in preparation.)

enter text here

(iii)List abstracts. (Attach if published, submitted or in preparation.)

enter text here

(Attach extra pages if needed.)Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

G.OUTLINE OF PROPOSED PROJECT

Do not exceed this page. It is easiest to draft your proposal in an unprotected document and to paste into the space provide. Highlight “Maximum of approximately 500 words” and paste in.

Maximum of approximately 500 words

(Attach figures and references only.)TO BE COMPLETED WITH PROPOSED SUPERVISOR

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

H.RELEVANCE OF PROPOSAL TO CBS RESEARCH

(Refer to at least one of four current research priorities .)

Do not exceed this table. It is easiest to draft your proposal in an unprotected document and to paste into the space provided. Highlight “Maximum of approximately 150 words” and paste in.

Maximum of approximately 150 words

I.APPLICANT’S IMMEDIATE AND LONG-RANGE CAREER PLANS

(Indicate how CBS-PDF will help facilitate these plans.)

Do not exceed this table. It is easiest to draft your proposal in an unprotected document and to paste into the space provided. Highlight “Maximum of approximately 150 words” and paste in.

Maximum of approximately 150 words

J.REFEREES

List three (3) referees you have asked to provide a statement of your qualifications.

Name / Position/Title / Address / Email / Phone #
1. enter name / enter position title / enter address / enter email / enter phone #
2. enter name / enter position title / enter address / enter email / enter phone #
3. enter name / enter position title / enter address / enter email / enter phone #

CBS-PDF SUPERVISOR INFORMATION

NAME:enter text hereTELEPHONE: enter phone #

LOCATION:enter locationFAX: enter phone #

EMAIL:enter email address

CBS POSITION:enter CBS position

UNIVERSITY APPOINTMENT:enter text here

UNIVERSITY POSITION:enter text here

NAME OF APPLICANT IN FULL (Surname in Capitals): enter text here

BRIEF OVERVIEW OF ENVIRONMENT

Please highlight facilities, resources and programs which will be made available to the candidate.

Do not exceed this table. It is easiest to draft your proposal in an unprotected document and to paste into the space provided. Highlight “Maximum of approximately 150 words” and paste in.

Maximum of approximately 150 words

DATE: SIGNATURE:

(No attachments to this page.)TO BE COMPLETED WITH PROPOSED SUPERVISOR

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

RESEARCH GRANTS HELD BY SUPERVISOR

(A Common CV Module may be submitted in lieu of pages 9 & 10).

List all research grants held during the last five years only. Include current and pending grants (indicate with an asterisk those grants pending decision).

Funding Agency / Amount($)/Year / Project Title / From (year) / To (year)
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date
enter amount / enter year / enter project title / enter start date / enter end date

PUBLICATIONS AND PRESENTATIONS BY SUPERVISOR

a)“Lifetime” Papers: enter text here

“Lifetime” Abstracts: enter text here

b)List peer-reviewed papers, book chapters/reviews and abstracts in the last five years only. (Attach extra pages if needed).

enter text here

(Attach extra pages if needed.)TO BE COMPLETED WITH PROPOSED SUPERVISOR

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

SUPERVISOR TRAINING HISTORY

List all past and currently supervised and co-supervised trainees, and all research personnel currently in your laboratory. Continue on a separate sheet if necessary.

Surname and Initials / Position / Project Title / Source of Support / Completion Date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date
enter surname & initials / enter position / enter project title / enter source of support / enter date

(Attach extra pages if needed).TO BE COMPLETED WITH PROPOSED SUPERVISOR

Page 1 of 11Form RD 40-14

2014 Postdoctoral Fellowship Application

Indicate if proposal involves:

BIOHAZARDS

a)Pathogenic agentsYesNo

Containment level required

1 / 2 / 3 / 4 / None

b)Recombinant geneticsYesNo

Containment level required

1 / 2 / 3 / 4 / None

c)RadioisotopesYesNo

Containment level required

1 / 2 / 3 / 4 / None

HUMAN EXPERIMENTATION

Has ethics approval been applied for?YesNo

ANIMAL EXPERIMENTATION

Has ethics approval been applied for?YesNo

TO BE COMPLETED WITH PROPOSED SUPERVISOR

Page 1 of 11Form RD 40-14