Application form for graduate studies at IRIC IDENTIFICATION AND CONTACT INFORMATION First name Last name Gender M Country of birth Date of birth (YYYY-MM-DD) F Status in Canada Canadian citizen Permanent resident International student Mailing address Email Phone (999-999-9999) Skype Account Language skills Fr Eng Reading skills Fr CHOICE OF STUDY PROGRAM I would like to join IRIC to pursue graduate studies at the: M.Sc. level Ph.D. level In the following program from Université de Montréal: Systems Biology Other program, please specify: I would like to start my training at IRIC: Semester: Summer (May) Fall (September) Winter (January) Year: RESEARCH INTERESTS Check off the boxes corresponding to your research interests: Antigen presentation Autoimmune diseases Biochemistry Bio-imaging Bioinformatics Bone marrow transplant Breast cancer Cell biology Cell differentiation Cell division Cell migration Cell proliferation Chemotherapy Chromatin Chromosomes DNA damage DNA microarrays Drug discovery Flow cytometry Genetics Genomics Hematopoiesis High-throughput screening Histology Histone acetylation Immunology Informatics Intracellular signaling Leukemia Mass spectrometry Medicinal chemistry Membrane receptors Metastases Model organism - C. albicans Model organism - C. elegans Model organism - D. melanogaster Model organism - M. musculus Model organism - S. cerevisiae Model organism - X. laevis Molecular and 3D modeling Molecular biology Nuclear receptors Other (specify) : Page 1 of 5 Oncogenes Pharmacology Proteomics Sequencing Stem cells Synthetic biology Systems biology Telomeres Transcription factors Transgenesis Tumor development Vesicular transport Virology Eng Application form for graduate studies at IRIC ACADEMIC BACKGROUND Outline your academic background; beginning with the most recent degree that you will have obtained prior to enrollment at IRIC: Diploma (e.g. B.Sc., M.Sc., Ph.D.) Name of the program / Field of study Name of the university City of the university Year of enrollment Year of graduation Grade point average (GPA) Country of the university Maximum GPA possible Diploma (e.g. B.Sc., M.Sc., Ph.D.) Name of the program / Field of study Name of the university City of the university Year of enrollment Year of graduation Grade point average (GPA) Country of the university Maximum GPA possible Diploma (e.g. B.Sc., M.Sc., Ph.D.) Name of the program / Field of study Name of the university City of the university Year of enrollment Year of graduation Grade point average (GPA) Maximum GPA possible Name of the program / Field of study Name of the university City of the university Year of graduation Grade point average (GPA) Page 2 of 5 Minimum passing GPA Country of the university Diploma (e.g. B.Sc., M.Sc., Ph.D.) Year of enrollment Minimum passing GPA Minimum passing GPA Country of the university Maximum GPA possible Minimum passing GPA Application form for graduate studies at IRIC ACADEMIC AWARDS Academic awards or scholarships that you have received SCIENTIFIC PUBLICATIONS AND PRESENTATIONS Contributions to scientific publications (references only) Oral or poster presentations during scientific meetings (name, location and date of the meeting, title of your presentation) Page 3 of 5 Application form for graduate studies at IRIC RESEARCH EXPERIENCE Indicate any relevant research experience (e.g. internship, summer job in a lab), from the most recent to the oldest: Name of employer Name and email address of your supervisor Position you occupied Description of your responsibilities Name of employer Name and email address of your supervisor Position you occupied Description of your responsibilities Name of employer Name and email address of your supervisor Position you occupied Description of your responsibilities Page 4 of 5 Application form for graduate studies at IRIC REFERENCES Provide details of a minimum of two persons who will act as referees in support of your application (only mandatory for Ph.D. candidates) First and last name Employer Position occupied Email address First and last name Employer Position occupied Email address SOURCES OF INFORMATION Do you follow IRIC on Facebook? Do you follow IRIC on Twitter? www.facebook.com/iric.udem www.twitter.com/IRIC_UdeM Yes Yes No No How did you hear about IRIC for the first time? IRIC website Family / Friend / Colleague Visit of IRIC Teacher (specifiy name) : Facebook IRIC Pizza Slice & Science Lunches Twitter IRIC Next Generation Internship Awards program Advertisement on UdeM campus Université de Montréal open house Advertisement on another campus Scientific event (specifiy name) : Television / Radio Graduate studies fair (specifiy name) : Newspaper / Magazine Other website (specify) : Scientific publication Other (specify) : Page 5 of 5