CUASF – BCC Research Grant | CUASF – Canadian Urological Association Scholarship Foundation

Name (in full) *

Date of birth *

CUA Membership Number *

Citizenship *

Mailing Address *

Email address *

Telephone # work *

Telephone # home *

Fax *

Name of Institution and Department where applicant will conduct his/her academic/research activities *

Academic Rank to be held by the applicant during tenure of the research *

Name, address and telephone number of the Department/Division Chair person *

Research Experience (a brief description of work in which the applicant has participated) *

Briefly describe the environment and the research facilities *

Briefly describe your long term career plans and research objectives and how this project will impact these objectives *

Date *

Place *

Name of Applicant *

Checklist

Research proposal

Evidence of appropriate Ethics Committee approval or application for approval along with consent forms where human subjects are involved in the study

Letter of support and commitment from the Chair of the Department/Division indicating the level of institutional and/or university support

A list of all current grants and submitted grant applications in the past 3 years (maximum of 1-2 pages) with the title of the grant, granting agency and amount of the grant. Incomplete applications will be disqualified.

A brief lay Summary (maximum of 250 words).