LYMPHOMA CANADA

Research Fellowship Supervisor’s Application Form for 2015-2017

PLEASE MAIL COMPLETED APPLICATION TO:

LYMPHOMA CANADA

ATTN: Judith Guzman

7111 Syntex Drive, Suite 351

Mississauga, Ontario L5N 8C3

Or

EMAIL TO:

A. General information

1. Research Fellowship Supervisor
Surname, Given name(s) / Position / Department / Faculty
2. Mailing address / Tel.
Fax.
Email.
3. Institution / This grant, if awarded should be paid through
(specify name of institution)
4. Short title of research / 5. Name and address of financial officer of
institution
6. Post-doctoral experience
Year of PhD or MD______
7. Indicate if proposal involves:
Human experimentation Yes  No 
Animal experimentation Yes  No 
Biohazards Yes  No 
8. The undersigned agree that the general conditions, as set out in the Lymphoma Canada Fellowship Guidelines, apply to any grant made pursuant to this application and are hereby accepted by the applicant(s) and the institution which employs the applicant(s).
Signatures:
______
Supervisor Date Financial officer Date

Name of Research Fellowship Supervisor______

B. Project information

Title of the research______

1. Lay summary (to fit on this page, font size 10 or greater)

Summarize in general terms the nature of the research to be conducted by the Fellow, its relevance to the understanding of lymphoproliferative disease and expected insights to be gained through this work (in lay language)

2. Scientific summary (to fit on this page, font size 10 or greater)

Provide a detailed description of the specific projects the Fellow will undertake, providing

sufficient information to judge feasibility, appropriateness of supervision, relevance to ongoing

work in the same laboratory, relevance to understanding of lymphoproliferative disease and

anticipated new insights which should emerge (in scientific language)

Name of Research Fellowship Supervisor______

C. Information About Research Fellowship Supervisor

1. Academic positions held

Dates
From - To / Institution / Department / Title

2. Awards or special appointments (past 10 years)

Award or special appointment / Date

Name of Research Fellowship Supervisor______

4. Specifically relevant publications

List up to a maximum of ten recent publications describing work for which the Research Fellowship Supervisor had major responsibility and which are related to the area of research that the Fellow will be performing under this Supervisor.

Name of Research Fellowship Supervisor______

E. Research Proposal

Submit a summary of the research to be undertaken by the Fellow during the fellowship term. This summary should include

  1. Detailed description of the project(s) on which the applicant will focus
  2. Indication of the relevance of this research to improved understanding of lymphoproliferative diseases
  3. Brief summary of relevance to other research being conducted in the same or closely associated laboratories
  4. Brief description of all duties and activities of the Fellow during the fellowship. This is intended to document that the maximum possible time will be devoted to the research project with minimum requirements for additional responsibilities.

References should not be exhaustive but rather reflect knowledge of important, directly related work. Tables, charts and figures should be directly relevant and included only if necessary for concise description of the planned research. This summary should not exceed 5 pages single spaced, font size 12, exclusive of 1 or 2 pages of tables, figures and references.

F. Attachments

1. Curriculum Vitae of the Research Fellowship Supervisor indicating previous student and fellowship research supervision, grant support and previous professional and research training and a list of publications from the past 10 years.

2. One letter of reference commenting on the Research Fellowship Supervisor’s experience and previous success in research supervision.

______

(Name of referee)

Lymphoma Canada

Confirmation of receipt of application form for 2015-2017 Research Fellowship Supervisor

(Please fill in both top and bottom sections and enclose a self-addressed envelope so we can return the

bottom portion to confirm receipt)

Name of Research Fellowship Supervisor ______

Address ______

______

Confirmation of Receipt

Name of Research Fellowship Supervisor ______

Date received:______

(To be filled in by Lymphoma Canada)

LC Research Fellowship Supervisor’s Application 2015 - 2017 Page1