PLEASE USE ONLY SINGLE SPACED, 11 POINT NON-CONDENSED FONT FOR ALL SECTIONS USE ONLY BLANK SPACE PROVIDED IN APPLICATION FORM SECTIONS Student No Family Name of Applicant Given Name Initial(s) Date of Birth School of Biomedical Engineering Dalhousie University 5981 University Avenue Room 5196, Dental Building Halifax, N.S. B3H 1W2 ADDRESSES Current Address Street Address Permanent Address (if different than current) Street Address City Province Post Code City Province Post Code Telephone No. Fax No Email address (will be used as initial point of contact) CITIZENSHIP Canadian Citizen Permanent Resident Other Country of Citizenship: PROGRAM RELATED Applying for: Masters PhD Post-Doc PROPOSED SUPERVISOR(S) Name 1. 2. Proposed Field of study/research Research Address Anticipated Start Date Jan Sept Year 20 Year of Study : 1 2 Title of proposed Research List 10 key words that describe your proposed research How did you hear about this program? SIGNATURE I hereby certify that all of the above information and all information on supporting documents are correct and complete. I agree that any award made to me as a result of this application will be subject to the general conditions governing NSERC scholarships, the Biomedic Create Program, and Dalhousie University including any revisions, deletions or additions made to them in the future. Applicant s Signature Date Please note: You and your supervisor/s will be notified of the results of this competition. Revised
Page 2 of 8 TRANSCRIPTS SUMMARISE HERE AND SEE NOTE BELOW ACADEMIC TRAINING / PROFESSIONAL EXPERIENCE TRANSCRIPTS MUST BE SENT FROM ISSUING INSTITUTION OFFICIAL TRANSCRIPTS ONLY. THEY MUST BE DELIVERED TO THE SCHOOL OF BIOMEDICAL ENGINEERING, UNOPENED AND BEARING THE INSTITUTION S SEAL. SUBJECT TO SAME DEADLINE AS APPLICATION. IF UP TO DATE TRANSCRIPTS HAVE ALREADY BEEN SUBMITTED AS PART OF AN APPLICATION TO ENROL IN THE SCHOOL OF BIOMEDICAL ENGINEERING, THE STUDENT CAN REQUEST FOR US TO USE THESE. UNDERGRADUATE TRAINING Date completed Degree/Major Department, Institution, Country Supervisor GRADUATE TRAINING (CURRENT AND/OR PREVIOUS) Date completed Degree/Major Department, Institution, Country Supervisor RELEVANT PROFESSIONAL EXPERIENCE (ATTACH ADDITIONAL PAGES IF NECESSARY) Dates Position & Topic Department, Institution, Country Supervisor CURRICULUM VITAE Please provide a CV (separate document) that includes the following: All publications -include thesis title & status (in progress /completed) Relevant distinctions and awards received Any other relevant experience REFERENCE LETTERS. Applicant must submit 2 reference letters as part of application. References must be sealed, with referee s signature on seal, and are subject to same deadline as application. Note: These can be letters previously used for admission to the School of Biomedical Engineering, and if previously submitted, the applicant can instruct the review committee to use these. Referee Name Address Email Address Letter sent separately Letter sent separately
Page 3 of 8 RESEARCH PROJECT GUIDELINES APPENDIX A RESEARCH PROJECT PROPOSAL PLEASE EXPLAIN HOW YOUR RESEARCH ALIGNS WITH THE GOALS, RESEARCH THEMES AND MISSION OF THE CREATE BIOMEDIC PROGRAM, HOW YOUR RESEARCH BRINGS TOGETHER CLINICAL APPLICATION AND BIOMEDICAL ENGINEERING, AND HOW IT CAN BE COMMERCIALISED IN THE FUTURE
Page 4 of 8 PAST, RELEVANT EXPERIENCE & FUTURE PLANS APPENDIX B PAST, RELEVANT EXPERIENCE & FUTURE PLANS DESCRIBE EXPERIENCE THAT IS RELEVANT TO YOUR RESEARCH AND FUTURE PLANS TO CONTINUE IN THE AREA YOU PROPOSE (USE SPACE PROVIDED, YOU MAY ALSO REFER TO YOUR CV).
Page 5 of 8 CURRENT FUNDING APPENDIX C STATEMENT OF APPLICANT S SALARY SUPPORT DESCRIBE YOUR CURRENT FUNDING AND ANY PROPOSED FUTURE FUNDING
Page 6 of 8 APPENDIX D SUPERVISOR(S) CV SUPERVISOR(S) CV CAN BE ATTACHED OR SENT SEPARATELY BY SUPERVISOR FORMAT OF SUPERVISOR(S) CV CAN BE CIHR COMMON CV OR THE NSERC EQUIVALENT), TO INCLUDE THE FOLLOWING INFORMATION: A) PUBLICATIONS FROM LAST 5 YEARS; B) RECORD OF GRADUATE/POST-GRADUATE SUPERVISORY EXPERIENCE; C) EXPERIENCE IN TRAINING RESEARCH PERSONNEL; D) SOURCE AND DURATION OF OPERATING FUNDING SUPPORT FOR THE PROPOSED PROJECT TO BE ATTACHED APPENDIX E SUPERVISOR(S) LETTER/STATEMENT OF SUPPORT ATTACH A LETTER FROM YOUR PROPOSED SUPERVISOR THAT DETAILS THE PROJECT AND HOW IT MEETS OUR PROGRAM GOALS. THIS IS LIMITED TO NO MORE THAN 2 PAGES, 12 POINT FONT SINGLE SPACED. NECESSARY COMPONENTS OF THIS LETTER ARE: DETAILS OF THE CLINICIAN MENTORING AND INVOLVEMENT INNOVATIVE ASPECTS OF THE PROJECT LABORATORY AND CLINICAL ENVIRONMENT RESOURCES & PERSONNEL OPERATING FUNDING FOR THE PROJECT TRANSLATION OR COMMERCIALISATION PATHWAYS ENVISIONED GENERAL FIT WITH THE GOALS OF THE CREATE PROGRAM APPLICANT ROLE IN RESEARCH PROJECT PLEASE INDICATE THE APPLICANT S ROLE IN WRITING OF PROPOSAL CHECK ALL THAT APPLY Applicant wrote Supervisor edited Supervisor wrote Other, please specify: SUPERVISOR(S) SIGNATURE (S) SIGNATURE OF SUPERVISOR DATE SIGNATURE OF SUPERVISOR DATE
Page 7 of 8 AGREEMENT APPENDIX F NSERC CREATE AGREEMENT If awarded an NSERC CREATE training award, I agree to fulfill the requirements of the program as described in Program requirements detailed in the application. Student Name (PRINT) Signature Date
Page 8 of 8 APPLICATION CHECKLIST PLEASE ENSURE YOUR APPLICATION INCLUDES ALL THE FOLLOWING. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. Supervisor Name/s and Project (Page 1) Signature (Page 1) Updated Transcript of marks if not already provided (copies may be included but official copy must be sent directly from the awarding university) Student CV in required format (additional to application form) Two References (to be sent directly to BME, see note) One page Student Letter describing the research and fit with goals (Appendix A) Supervisor/s CV (see Appendix D) Supervisor Letter (see Appendix E) NSERC Agreement Letter (Appendix F) Please send completed application form to: Eleanor Seaman-Bolton Program Coordinator, NSERC CREATE: BioMedic via email:esb@dal.ca Note: Electronic forms are acceptable but may not include signatures, so please submit a hard copy of signature pages by mail. or by mail/courier at: School of Biomedical Engineering, Rm 5196 Dalhousie University, 5191 University Ave. Halifax, N.S. B3H 1W2