APPLICATION FORM IDENTIFICATION AND CONTACT INFORMATION First name Last name Gender M Country of birth Date of birth (YYYY-MM-DD) F Status Quebec resident Canadian citizen Permanent resident of Canada International student, specify your country of citizenship: Mailing address Email Phone (999-999-9999) Skype Account Language skills Fr Eng Reading skills Fr TRAINING PROGRAM I would like to join the IRIC to pursue a: Masters (MSc) degree in the following program: Systems Biology (fast-track 1-year program, includes 2 laboratory rotations) Other program (2-year program) Doctorate (PhD) degree in the following program: Systems Biology (4-year to 5-year program) Other program (4-year to 5-year program) I would like to start my training at IRIC: Term: 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 Molecular and 3D modeling Molecular biology Nuclear receptors Other (specify) : Page 1 of 5 Pharmacology Proteomics Sequencing Stem cells Synthetic biology Systems biology Telomeres Transcription factors Transgenesis Tumor development Vesicular transport Virology Eng APPLICATION FORM 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 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 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 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 OTHER Do you follow IRIC on Facebook? Yes Do you follow IRIC on Twitter? No Yes No How did you hear about the IRIC for the very first time? IRIC website Other website, specify: IRIC Next Generation Awards program Graduate school fair or other recruitment event, specify: Scientific meeting, specify: Promotional flyer/poster on the campus of the UdeM Promotional flyer/poster on the campus of another university COOP or internship database, specify: Teacher or program coordinator, specify: Student association, specify: Current or past member of the IRIC, specify: Friend or family member Other, specify: Page 5 of 5 Do you follow IRIC on LinkedIn? Yes No