Department of Medicine
Translational Research Fellowship Application Form
Deadline for receipt of award applications is Friday March 4th, 2016. Please submit your completed
application package in a single PDF format to domreas@ualberta.ca. Questions regarding the
completion of this form can be directed to Eleni Karageorgos, Team-Lead, using the e-mail address
provided above.
SECTION 1: PERSONAL DATA
Candidate Name: Surname, First Name, Initial(s)
Trainee Category (please select one):
Graduate Student
Birth date:
Year
Resident
Postdoctoral Fellow
Gender:
Month
Day
Male
Female
Contact Information:
Phone:
E-mail:
SECTION 2: SUPERVISOR DATA
Supervisor(s) Name:
Supervisor Contact Information:
Phone:
E-mail:
SECTION 3: PUBLICATION
Title of Publication
Application 1
Journal Name
Translational Research Fellowship
Funded by: Department of Medicine
Department of Medicine
Translational Research Fellowship Application Form
SECTION 4: AWARDS
Starting with the most recent, indicate any awards, fellowships and scholarships received
Name/Title and Type
Institution/Organization and
Country
Effective
Date
(MM/YYYY)
End Date
(MM/YYYY)
Total
Amount
SECTION 5: SIGNATURES
The undersigned agree to and accept the general conditions governing any award made pursuant to the
sponsorship of this application as outlined in the Terms of Reference for this award
Signature
Candidate:
Printed Name
Date
Supervisor(s):
Attachments:
250-word summary describing the translational nature of the work
Applicant’s CV
Manuscript - please indicate whether the paper is:
Published
In press (please include proof from the journal that the paper has been accepted)
Application 2
Translational Research Fellowship
Funded by: Department of Medicine