Research Training Bursary 2016:
Level 1 to 3
APPLICATION FORM
After completion this form should be returned to:
Pharmacy Research UK
66-68 East Smithfield
London E1W 1AW
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CHECKLIST
I confirm that I:
☐Am a member of the Royal Pharmaceutical Society. My membership number is …………………………….
☐Have completed all sections of this Application Form
☐Have included brief CVs (my own and all supervisors listed in my application)
☐Have obtained all necessary supporting signatures in Section 7 (Declarations)
☐Have included a cover letter
☐Have included two hard copies of the application form
☐Have emailed this Application Form and any supplementary documents to:
Research Training Bursary
Pharmacy Research UK
66-68 East Smithfield
London E1W 1AW
Practice.Research@rpharms.com
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SECTION 1: PERSONAL DETAILS
Name
Title
First name
Last name
Home Address
Postcode
Telephone No.
Mobile No.
Email
GPhC Reg No.
Date of registration:
If you are not currently registered, are you undertaking pre-registration training? Yes ☐ No ☐
Please indicate which level you are applying for (by placing an ‘x’ in the appropriate box below).
☐
☐
☐
Level 1
Level 2
Level 3
Where did you hear about this research funding?
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SECTION 2: CURRENT EMPLOYMENT DETAILS
Post Held
Organisation
Address (of branch if applicable)
Postcode
Work Tel. No.
Email
Current Salary
£
Please provide a brief outline of your responsibilities – Max 250 words
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SECTION 3: DETAILS OF PROPOSED TRAINING
Training to be undertaken (course title and provider details)
Course start date
Course completion date
Is the course
Have you applied for a place?
(please place ‘x’ in the
appropriate box)
Bursary start date
Bursary end date
Full-time ☐
Yes ☐
Total cost requested
£
Part-time ☐
No ☐
Training Programme – Maximum 500 words
Please summarise the formal training you wish to undertake. Please include details of modules
(compulsory and optional) you wish to study and the length of the project (months) and /or
dissertation (words).
Proposed topic for research – Maximum 500 words
Please outline the topic you intend to pursue.
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SECTION 4: YOUR PROFESSIONAL DEVELOPMENT THROUGH RESEARCH
Professional and personal development – maximum 500 words
Please describe how you intend to actively pursue research and how this bursary will help you achieve
your aspirations.
Past involvement in Research – maximum 500 words
Provide details of research, if any, you have been involved in to date.
How do you plan to balance your current work activities with your proposed research project and
training? (maximum 250 words)
Value of the Project – maximum of 500 words
How do you see the results of your project contributing to our knowledge of health and healthcare
generally and the aims of Pharmacy Research UK specifically?
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SECTION 5: SOURCES OF ADVICE AND SUPERVISIONS
Please provide details of the person(s) consulted for the elements listed below (if any) when
completing this application. Please also indicate if any of the advisers have seen your completed
application form.
Study Design
Name
Email
Telephone
Statistics
Name
Email
Telephone
Budgeting /Finance
Name
Email
Telephone
Ongoing support and supervision
Please provide an outline of the support to be given
Details of TWO referees (Pharmacy professionals, need not necessarily be current employer)
Title
Title:
Name
Name:
Position
Position
Address:
Address
Postcode:
Telephone
Postcode
Telephone
Email
Email
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SECTION 6: FINANCE
Please provide the details of the support requested, including personal support based on course
attendance and research time, course fees, research, supervision, and conference costs.
Details
Year 1 – Amount (£)
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Year 2 – Amount (£)
(if applicable)
SECTIONS 7: DECLARATIONS
APPLICANT
I wish to apply for a Resarch Training Bursary for the year 2016 on the basis of the information given in
this appication.
I declare that I will be actively engaged in, and in day to day control of the project.
I agree that Pharmacy Research UK may hold and process, by computer, or otherwise, personal and
other data contained within this application and, if successful, additional data requested.
Signature
Date
Name (BLOCK CAPITALS)
EMPLOYER – IF APPLICABLE
I agree that If the applicant is successful in securing a place on a course and funding, arrangements
will be made to permit attendance at the institution and to undertake the research project:
Yes ☐
Signature
No ☐
Non applicable ☐
Date
Name (BLOCK CAPITALS)
Post Held
Organisation
Address
Postcode
Tel. No.
Email
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FOR THE HEAD OF DEPARTMENT OR ORGANISATION:
I declare that I have read this application and that, if funded, the work will be accommodated and
administered in the department / organisation and that the applicants for whom we are responsible
may undertake this work.
Signature
Date
Name (BLOCK CAPITALS)
Post Held
Organisation
Address
Postcode
Tel. No.
Email
FOR THE ADMINISTERING ORGANISATION’S FINANCE DEPARTMENT, to be signed by finance officer
or equivalent:
I declare that the financial information given on this form is complete and correct and agree to
administer the award, if made. The staff grades and salaries quoted are correct and in accordance
with the normal practice of this organisation.
Signature
Date
Name (BLOCK CAPITALS)
Post Held
Organisation
Address
Postcode
Tel. No.
Email
Please return two hard copies and one electronic copy of this form to:
Research Training Bursary Scheme
Pharmacy Research UK
Royal Pharmaceutical Society
66-68 East Smithfield Street
London E1W 1AW
Tel: 02075722455
Email: Practice.Research@rpharms.com
By 5pm on Wednesday 4th May 2016.
Please ensure this form is fully signed before submitting and you have attached relevant CVs.
Please note: Late or incomplete applications will not be accepted
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