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)

Letter outlining the clinical and/or research plan for fellowship not exceeding (5) single-spaced pages (please see suggested headings in Terms of Reference)

A maximum of three (3) published reprints or pre-prints (if applicable)

Project budget

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 support and commitment by the university/institution for the candidate.

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