TCRN PhD Scholarship Top-upAwards 2013

Application Form

NOTE: Prior to completing this application form, ensure that you have done the following
  • Read and understood all/any Guidelines relevant to the Scholarshipbeing applied for
  • Provided all relevant information and documentation. Incomplete applications or missing documents will result in your application not being considered.

1. Scholarship Details
TCRNPhDScholarship Top-up
Scholarship being applied for
First-year student: 3-year top-up Second-year student: 2-year top-upFinal-year student: 1-year top-up
2. Applicant Details
UTSstudent number:
Family Name: / Given name:
Male Female / Date of birth (dd/mm/yyyy):
Domestic Student International Student
Postal address (home)
Number: Street:
Suburb: / State:
Postcode: / Country:
Home phone: / Mobile:
Email address:
3. Current Scholarships
Are you currently receiving any other awards or scholarships at UTS? / Yes*
Pending*
No
*If Yes or Pending, please provide information below
What is the name of the award/scholarship? / 1.
2.
3.
What is the annual monetary value of the award(s)? / 1.
2.
3.
What is the exact duration of the award?
Please provide exact start and expiry date(s). / 1.
2.
3.
4. Current Program
4a. Enrolment Details
Faculty: / Date of commencement:
School: / Expected completion date:
Enrolment status:Full-time Part-time Note: part-time students are not eligible for the award
4b. Supervisor Details NOTE: Primary supervisor must be a listed TCRN member. Refer to Guidelines for further details.
Name of PrincipalSupervisor:
Name of Joint PrincipalSupervisor:
5. Academic Qualifications – Undergraduate & Postgraduate
Details of previous Study / Name of award held (if any) / Monetary value / Period held / Institution / Years of enrolment / Year graduated
From / To / From / To
Example
B.E / $ / University of XYZ / 2002 / 2007 / 2008
6. Relevant Research Experience
Briefly describe your previous research experience including any relevant employment.(max 250 words)
7. Research Publications
Provide citation details of any previous research publications.Indicate the publication category and where sole- or first-authorship applies.
Conference paper / research report / Book / chapter / Peer-reviewed journal article / First / sole author
8. Research Plan
Topic Area:
Project Name:
Background:
Hypothesis/Aims:
Progress to-date:
Key objectives and milestones:Suggest to presentmilestonesfor each year of study
9. TCRN Core Strengths
To which (if any) of the following TCRN core strengths does your research apply?
Molecular basis of cancer New therapeutics Clinical trials
Cancer epidemiology Health services research Health Economics
Adultcancer areas
Ovarian cancer Brain tumours Haematological malignancy Gastrointestinal tract malignancy
10. Translational Relevance
Describe how your research will translate into improvements in patient care and clinical outcomes (max 250 words)
11. Statistical Research Plan
1)Does your research plan include statistical analyses? Yes No (explain why not)
2)Will you require additional statistical support for your research?
Yes (describe any statistics training, e.g. course/workshop, you have already taken and outline the support you require)
No (explain why no statistical support is needed)
12. Consumer Engagement
Describe how your research has engaged/will engage cancer consumers in the planning, implementation and/or information dissemination stages. (max 100 words)
13. Checklist
The following checklist is designed to ensure that you have provided all documentation required for your application to be processed. The checklist must be completed prior to submission.If there is any information that you are unsure of, or if you require further information, please contact the TCRN Operations and Projects Team:
I have:
Fully completed this scholarship application form
Attached a copy of my competitively awarded scholarship application (e.g. APA or equivalent)
- Certified copies or originals of academic transcripts (clearly legible)
- Curriculum vitae
Attached a letter from my primary supervisor indicating that there are sufficient resources to complete the research project in accordance with UTSOH&S standards
Additional comments regarding your application:
14. Privacy Notification
The University of New South Wales (UNSW) acknowledges and respects the privacy of individuals. The information you provide on this application for is “personal information” as defined by the Privacy and Personal Information Act, 1998 (NSW) (the Act).The information you provide is collected and held by the Translational Cancer Research Network(TCRN) in order to assess your application and for administrative and statistical purposes. You have the right of access to, and alteration of, the information concerning yourself in accordance with the Act and the UNSW Privacy Management Plan. The TCRNwill not disclose your personal information without consent and without due cause, except as required by law. You have the right to refuse this consent, but if the consent is not given your application may not be processed.
Applicant’s signature: / Date:
15. Declaration
In submitting this application for a TCRN PhD Scholarship Top-up:
I have:
  • Answered all questions on this form truthfully.
  • Read the relevantGuidelines and understand the eligibility criteria and conditions of this award.
I agree to:
  • Notify the TCRNof any change to the information I have given in this application.
  • Authorise TCRN to obtain from any other educational institution or relevant authority, at anytime, details which relate to my Scholarship application including information concerning my enrolment record, examination results, enrolment variation and attendance.
  • Abide by the TCRNconditions of the award, as amended from time to time.
  • Comply with UTS rules on admission, enrolment and other policies on the conduct of research.
  • Undertake to obtain ethical clearance and satisfy any other regulatory requirements before commencing any research to which those requirements may apply.
I understand that:
  • UTS or TCRN may disclose information concerning this application to any person or body UTS or TCRN considers has legitimate interest in receiving it and I consent to such disclosure.
  • UTS or TCRNmay vary or cancel any decision it makes if the information I have given is incorrect or incomplete.
  • I will not be sent notification that my application has been received.
  • I must not receive scholarships from different institutions simultaneously.
  • is not responsible for the loss of any documents submitted.
  • My application processing will be delayed if I have not provided all documents as detailed throughout the form and on the checklist.
  • If I am offered a scholarship, I will not be able to defer that offer.
  • Giving false or misleading information is a serious offence under the Criminal Code (Commonwealth).
  • My application will not be processed if I have not confirmed that I agree with this Statement by signing below and dating this application form with the date of submission.

16. Agreement
APPLICANT NAME / SIGNATURE / DATE / ___ / ___ / ___
THE APPLICATION MUST BE LODGED BY THE CLOSING DATE:
9am Monday 25March 2013
Email the application form and supporting documents, scanned as a single PDF, to
Translational Cancer Research Network
A translational cancer research centre program funded by the Cancer Institute NSW
Level 4 | Lowy Cancer Research Centre | The University of New South Wales | UNSW Sydney NSW 2052
T: +61 2 9385 1395 | | / 1 of 4