March 10, 2016

Re: Henry R. Shibata Cedars Cancer Fellowship

Dear Healthcare Professional,

You will find attached the application form for the 2016 Henry R. Shibata Cedars Cancer Fellowship and the Kate McGarrigle Fellowship in Sarcoma. However, please note that an on-line version, that can be completed and sent by email to , can be accessed through our website: http://www.cedars.ca/cedars/en/funds_and_fellowships/henry_shibata. These grants are sponsored by the Cedars Cancer Foundation and are designed to provide salary support to either clinicians who wish to pursue additional fellowship level training in oncology abroad or to young basic scientists initiating research at the MUHC. Those electing to pursue fellowship training are expected to return to the MUHC once completed. Successful candidates will be announced in June for the awards which will be granted in the fall of the following academic year. Preference will be given to those who are committed to continue their careers at the MUHC.

Please feel free to apply or pass this application on to any worthy applicants who may be interested in this fellowship in oncology research.

Please mail or e-mail the following documents to the coordinates below.

1. Original enclosed application

2. Two (2) letters of recommendation one of which must be from your current supervisor, chair or
program director

3. A letter from the applicant’s supervisor is required, confirming applicant’s acceptance and a critic
appraisal of the proposed project.

4. Curriculum Vitae (12 copies only if mailed) – To include information on teaching and research
positions, list of publication, certificates, awards, scholarships, memberships etc…

5. Eleven (11) copies of the original application (only if mailed), 1 copy if e-mailed.

The Cedars Cancer Foundation

Henry R. Shibata Fellowship Award

c/o Mr. Jeff Shamie

2155 Guy St, Suite 900

Montreal, Quebec

H3R 2R9

or e-mail at

For more information please see our website:

http://www.cedars.ca/cedars/en/funds_and_fellowships/henry_shibata

**ALL APPLICATIONS MUST BE TYPED**

The application deadline is May 12, 2016 .

With best personal regards,

Dr. Roger J Tabah, MD

Chairman, Cedars Fellowships and Awards Committee


2016 HENRY R. SHIBATA CEDARS FELLOWSHIP

AWARD APPLICATION FORM

TITLE
Click here to enter text. / FIRST NAME & INITIAL
/ LAST NAME
PERMANENT ADDDRESS / CITY & PROVINCE / POSTAL CODE
HOME PHONE
/ WORK PHONE
ext. / CELL PHONE
DATE OF BIRTH (yyyy/mm/dd)
/ SOCIAL INSURANCE NO.

TOPIC RESEARCH AREA:

SUPPORT REQUIRED FOR: RESEARCH PURPOSES: ☐

CLINICAL TRAINING: ☐

The aim of the Henry R. Shibata Cedars Fellowship is to assist health professionals in their training and careers. If they are meritorious and have not obtained funds from granting agencies or from other sources, they will be considered for a FELLOWSHIP.

REQUIREMENT: At the end of the FELLOWSHIP, a brief summary of work accomplished and future goals should be submitted to the Chairman of the Cedars Fellowship and Awards Committee

ACKNOWLEDGMENTS: Publications resulting from the efforts of the FELLOWSHIP should bear an acknowledgement to the Cedars Cancer Foundation of the McGill University Health Centre.

Amount Requested:

Signature: Date:

The applicant is responsible for submission of a complete application (fully typed) prior to the May 12, 2016 deadline. The complete application includes two (2) letters of recommendation (one of which must be from your current supervisor, chair or program director), your curriculum vitae, the original application and (11) copies (if mailed) of the application. Incomplete applications will not be considered.

1.  FULL NAME OF APPLICANT:
2.  PRESENT ADDRESS
PRIMARY TELEPHONE #:
FAX NUMBER:
EMAIL ADDRESS:
3.  PRESENT APPOINTMENT:
4.  ULTIMATE CAREER GOALS:
5.  EDUCATION
DEGREE: / COURSE:
UNIVERSITY: / YEAR:
DEGREE: : / COURSE:C COURSE:
UNIVERSITY: / YEAR:
6.  EXPERIENCE
a) ACADEMIC
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:
b) CLINICAL
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:
c) RESEARCH
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:
DATES: / POSITION:
DEPARTMENT: / INSTITUTION:

7.  Teaching Experience: Small Group Teaching and Clinical Teaching:

8.  Distinctions and awards:

9.  Current interests or job development goals:

10.  Membership in professional and scientific societies:

11.  Publications: List papers published in the last five (5) years. Only full-fledged peer review journals are to be listed. Give author, journal, page and year only; list abstracts separately:

12.  Nature of proposed program:

13.  Name other agencies to which application for personal support has or will be made:

14.  Name of supervisor, department, location and contact information at which applicant has arranged to carry out training/research:

15.  A letter from the applicant’s supervisor is required, confirming applicant’s acceptance and a critical appraisal of the proposed project.

16.  Application to include letters of recommendation from two peers, one of which must be from applicant’s current supervisor, chair or program director and the other from someone under whom the candidate has worked.

17.  Recommendations
Recommendation #1:
NAME: / ADDRESS:
PRIMARY TEL., ext. / EMAIL:
Recommendation #2:
NAME: / ADDRESS:
PRIMARY TEL., ext. / EMAIL:

18.  I certify that the information recorded herein is complete and accurate. I recognize that any falsified documentation or evidence at the time, or subsequently found, will be basis for dismissal from the programme.
I hereby grant my permission to contact previous programme directors or any person/institution cited in this application or appendices for further reference.

Dated at: this day of 2016.

Signature:

19.  Approval of Department Head

Name of Department Head:

☐Yes ☐No

Signature of Department Head Date:

(For office use only)

Cedars Cancer Foundation Fellowship Application

Action of the Committee

Approved: ______Amount Recommended: $______

Not Approved: ______

Signature: ______Date: ______

Print Name: ______