MMI Clinical & Translational Research Scholars Programme (CTRSP)

MMI Clinical & Translational Research Scholars Programme (CTRSP)

Application Form

The closing date for receipt of applications is5pm, Tuesday 26 April 2011.

For information on the MMI Clinical & Translational Research Scholars Programme please see

1. Personal Details

Title Mr/Mrs/Miss/Ms/Other
(specify) / Last Name / First Name / Middle Name(s)
Date of birth (DD/MM/YY) / Gender (M/F) / Nationality / Place of Birth
Permanent Address / Address for correspondence (if different)
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Postcode……………………………Country…………
Telephone Number…………………………………..…………..
Mobile Number…………………………………………………… / …………………………………………………………………
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Postcode……………………………Country……………………
Telephone Number…………………………………..…………..
E-mail Address………………………………………………………………………………………………………………………….

1. Current Study (if applicable)

Degree / Major Subject / Expected Completion Date / Institution Name / Student No.

1. Education

Qualification / Major Subject / Completion Date / Result / Institution Name / Student No.

1. Please list any Academic Awards or Scholarships received.

1. Please give details of your research experience.

1. Select your preferred host institution for the Clinical & Translational Research Scholars Programme (CTRSP) by checking the relevant box. (Note: please select one institutiononly).

NUI Galway
Trinity College Dublin
University College Cork
University College Dublin

1. How did you hear about the MMI Clinical & Translational Research Scholars Programme?

1. Please write a brief statement (max. 1000 words) outlining your interest in and suitability for the MMI Clinical & Translational Research Scholars Programme.

1. Please provide any other relevant information.

1. Academic References

We require two references that indicate your academic suitability and potential to undertake postgraduate research in the MMI Clinical & Translational Research Scholars Programme.

1. Please provide the names and contact details for each of your referees below.
2. Download the Academic Reference Form available at
3. Fill out Section A in two copies of the Academic Reference Form and provide these to your referees.
4. Each of your referees should then complete Section B of the Academic Reference Form and returnto Molecular Medicine Ireland, to be received by 5pm Tuesday, 26 April 2011.

Please note that it is the applicant’s responsibility to ensure that referees return the completedAcademic Reference Formsto Molecular Medicine Ireland by this date.

Name / Address / Position / Contact Details
Email:
Telephone:
Email:
Telephone:

1. EU/non-EU Status

Are you eligible for EU status for the payment of fees? Yes ______No______

Declaration

Please type your name in the box below to indicate that the information you have provided is true to the best of your knowledge. You will be asked to sign the form if selected to attend for interview.

Applicant’s Signature / Date

Please return this completed form as an email attachment together with a Curriculum Vitae(max. 3 page) to 5pm, Tuesday 26 April 2011.

The two completed Academic Reference Forms must also be receivedby Molecular Medicine Ireland by 5pm, Tuesday 26 April 2011.

Applicants whose primary language is not English must submit a TOEFL or IELTS certificateindicating that they have attained a reasonable command of English, the equivalent of either TOFEL score of 550 or IELTS score of 600.For further details please see or

Please note that you may be asked to provide transcripts of your academic record should you progress to the later stages of the selection process.

The MMI Clinical & Translational Research Scholars Programme is funded under the Programme for Research in Third Level Institutions (PRTLI)