CUA-Pfizer Incontinence Fellowship 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 *

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 fellowship will impact these objectives *

Date *

Place *

Name of Applicant *

Checklist

Curriculum Vitae of Fellow (Please submit a pdf version of your Common (CIHR) CV)

Research proposal outlining the clinical and/or research project for the fellowship not exceeding (5) single spaced pages including budget and references all in standard 12 font (please see suggested headings outlined below). Note: The CUA-Pfizer Incontinence Fellowship Award is not intended to fund the research project. The institution at which the fellowship takes place will need to provide funding for the research project.

A detailed plan to apply for appropriate Ethics Committee approval and Regulatory approval (Clinical Trial Application in cases of non-marketed drugs or marketed drugs where the proposed use is outside the parameters of the Notice of Compliance) must be included along with the consent forms where human subjects are involved in the research project considered.

Letter of support from the academic institution fellowship program director or alternate agreeing to conform to the Terms of Reference. The letter should indicate the level of non-monetary support, infrastructure and commitment by the university/institution for the candidate.