Pharmacology Honours Expression of Interest Form

Pharmacology Honours Expression of Interest Form

Please return form toBarb Kemp-Harper in the Department of Pharmacology

This is an Expression of Interest form only and does not constitute an offer of a place in the Pharmacology Honours program or university or entitle an applicant to be classified as a student of the university. The form should be completed and returned to Dr Barbara Kemp-Harper in the Department of Pharmacology.

Once results are known, andif you meet the necessary criteria, you will be contacted by the Faculty of Science and Department of Pharmacology,.

Section 1: To be completed by applicant

ID No:
Family Name: / Title:
Given Names:
Mailing Address:
Monash Email Address:
Telephone Number:

Student Signature: ______Date: ______

Section 2: Project selection (to be completed by applicant and potential supervisor)

The purpose of this form is for you to indicate the project of your choice.

PROJECT INFORMATION

Project Title:

Location:

Main Supervisor:

Main Supervisor to complete(MUST BE SIGNED).

(1)I have discussed this project with the student and I have agreed to

supervise the student on this project. YES NO

(2)Have the appropriate ethics approvals been granted or applied for? YES NO

(3)Do you anticipate being absent for any periods in excess of
2 weeks during the academic year? YES NO

If yes, please advise time and duration of absence: ______

(4)I have completed the level 1 MGE supervisor accreditation training YES NO

(5) How many honours students have you supervised? BMS ______BSc______Other______

Print Name:______

Signature: ______Date: ______

Co- Supervisors to complete(MUST BE SIGNED). All students are required to have a co-supervisor.

(1)I have discussed this project with the student and I have agreed to

co-supervise the student on this project. YES NO

(2)Do you anticipate being absent for any periods in excess of
2 weeks during the academic year? YES NO
If yes, please advise time and duration of absence: ______

(3)I have completed the level 1 MGE supervisor accreditation training YES NO

(4) How many honours students have you supervised? BMS ______BSc______Other______

Print Name:______

Signature: ______Date: ______

Honours Convenor to complete(MUST BE SIGNED).

I fully support this application and I am satisfied that appropriate resource/s, permit/s and supervision is/are available in this Department/School/Institute for successful completion of the above named project.

Print Name: ______

Signature: ______Date: ______

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