John Buckingham Application Form
JOHN BUCKINGHAM TRAVELLING SCHOLARSHIP APPLICATION FORM
GUIDE TO COMPLETING THEAPPLICATION FORM
Applicants must read these instructions carefully before submitting an application
1.Prior to completing the application form applicants must read the Award Policies to ensure their eligibility. These can be found on the Scholarship Policy page of the RACS website at Applicants must also read the applicable Important General Information section for their award at
2.Applicants must submit an application on the prescribed form, where applicable, accompanied by a brief CV. The format of the application form must not be altered in any way. Applications are not to be handwritten.
3.Do not submit the application form or CV bound or on coloured paper.
4.Unless otherwise stated, or unless in exceptional circumstances, applicants must not have commenced their travel prior to the closing date for applications.
5.Confidential reference reports from those identified in the application must reach RACS by the closing date for applications. It is the applicant’s responsibility to ensure this occurs. Reports received after this time maynot be considered. It is essential that you inform the persons from whom you request these reports that they must reach RACS by the closing date for applications.
6.Applicants must email their application and CVto no later thanmidnight ACST on30 September2017.
Applications received after this datewill not be considered. It is the applicant’s responsibility to ensure the application is received by the ANZ Scholarship and Grant Coordinator
Contact Details:
Mrs Sue Pleass
ANZ Scholarship and Grant Coordinator
Research and Scholarships Department
Royal Australasian College of Surgeons
199 Ward Street
NORTH ADELAIDE SA 5006
Phone: +61 8 8219 0900 Fax: +61 8 8219 0999
Email:
ELIGIBILITY FORM
Please read the following condition statements for the available Fellowship and indicate by ticking the eligibility box t that you satisfy all the conditions.
Award / Conditions Statement / Eligible? (Yes/No)John Buckingham Travelling scholarship / Are you a RACS Australian or New Zealand SET Trainee? / YES NO
☐ ☐
Are you available to travel to Boston, USA, during October 2018 to attend the American College of Surgeons (ACS) Annual Clinical Congress?
If successful, are you available to attend the RACS Annual Scientific Congress in May 2019 in Bangkok? / YES NO
☐ ☐
YES NO
☐ ☐
SECTION A – Applicant’s Details
Surname/Family Name / Click here to enter text. /
Given Names / Click here to enter text. /
Title / Click here to enter text. / Gender: / Click here to enter text.
Full Postal address
(including state and postcode) / Click here to enter text. /
Is this a work or a home address? / Click here to enter text. /
Home Telephone / Click here to enter text. / Business Telephone / Click here to enter text. /
Mobile Number / Click here to enter text. / Fax Number / Click here to enter text. /
Email / Click here to enter text. /
Are you an Australian or New Zealand SET Trainee or have you applied for SET? / YES
☐ / NO
☐ / Applied
☐
What is your current SET level? / Click here to enter text. /
What is your Specialty? / Click here to enter text. /
Are you a member of or have applied for Resident Membership of the ASC, with the YES NO
intention of gaining Fellowship of the ACS in the future ☐ ☐
Are you are a member or intending to become a member of the ANZ Chapter of ACS. YES NO
☐ ☐
Are any aspects of your practice under review? YES NO
If yes, please provide details: ☐ ☐
Do you have restrictions placed on your practice by a regulatory authority or hospital? YES NO
If yes, please provide details: ☐ ☐
SECTION B – Qualifications and Employment
/ Please complete the following details relating to your present employment
/ Employer/Source ofFunding / Click here to enter text. /
Tenure
(If untenured, please give date of termination of current post) / Click here to enter text. /
Grade/Status / Click here to enter text. /
2. / Please list your PREVIOUS post-graduate appointments in date order, starting with most recent
/ Place of Work / Posts Held / Date
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3. / Please list below all your university qualifications and post graduate degrees, including the year of award and institution, starting with the most recent
Qualification / Institution / Year
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4. / Please detail below any noteworthy academic achievements in your career to date:
Click here to enter text.
5. / What are your career intentions?
Click here to enter text.
SECTION C – Complete the applicable questions in this section
6. / What research experience have you had to date?
Click here to enter text.
7 / Have you applied for or received any other grants/awards/scholarships for 2018? / YES
☐ / NO
☐
8 / If YES, please provide details:
Click here to enter text.
SECTION D – Proposed Travel Details
9.. / Please complete the following details relating to the proposed duration of the travel.
Applicants must not have commenced their travels prior to the closing date for applications.
Proposed Commencement of Travel / Proposed Completion of Travel
10.. / Please provide a 1000 worddissertation outlining the potential benefits to yourself, the ANZ Chapter of the ACS and RACS from this scholarship.
Click here to enter text.
SECTION E – Referee Reports
11. / Please provide the name and contact details of the person who has supplied Reference 1.
Name (including Title) / Click here to enter text. /
Position / Click here to enter text. /
Contact Address / Click here to enter text. /
Telephone Number / Click here to enter text. /
Email Address / Click here to enter text. /
12.. / Please provide the name and contact details of the personwho has supplied Reference 2.
Name (including Title) / Click here to enter text. /
Position / Click here to enter text. /
Contact Address / Click here to enter text. /
Telephone Number / Click here to enter text. /
Email Address / Click here to enter text. /
SECTION F – SIGNATURE
I certify that the information supplied in this application is true and correct. I understand that the Royal Australasian College of Surgeons may wish to verify this information with an institution or individual. I consent to such inquiries being undertaken as part of the scholarship selection process. I have read the application conditions for the relevant scholarships, fellowships and grants and agree to abide by them.
Signature / Click here to enter text. /
Date
SECTION G – Your Personal Checklist
Application Form completed and signed
Eligibility form completed
References attached/requested
CV attached
2018 Travel Application- 1 -