Lakehead University – Paleo-DNA Laboratory – Application for Visiting Researcher Status
Paleo-DNA Laboratory
Application for Visiting
Researcher Status
1294 Balmoral Street Suite 300
Thunder Bay, ON P7B 5Z5
807-343-8877
CONTACT INFORMATION
Family name of applicant
Given name and initial(s)
ADDRESSES
Current Address
Permanent mailing address (if different than
Emergency contact address
current address)
Current telephone number
Permanent address telephone number
Emergency contact telephone
If current address is temporary, indicate
Fax number
Email address
leaving date
CITIZENSHIP
Canadian Citizen
Permanent Resident of Canada
Indicate date of landing as per FORM IMM 1000
Other:
Indicate country of Citizenship
SIGNATURE
I hereby agree that all information provided is true and accurate.
______________________________________
Applicant’s Signature
Page 1 of 3
_____________________________________
Date
Personal information collected on this form and appendices will be stored at the Paleo-DNA Laboratory
PROTECTED WHEN COMPLETED
Lakehead University – Paleo-DNA Laboratory – Application for Visiting Researcher Status
Page 2 of 3
DESCRIPTION OF ACADEMIC SUPPORT
Please provide information re: the level of academic support to be provided by the host department/program (secretarial/technical assistance, office
space, telephone, fax, photocopying, etc.)
*Please note that library, athletic and parking privileges are available at a cost to visiting scholars.
**Please note that ALL foreign visiting scholars must secure UHIP Health Insurance and provide details re: coverage from their host institution.
PROPOSED PLAN OF RESEARCH
(specify):
Does the research involve the use of:
Or attache
Please provide a description of the proposed plan of research including anticipated collaborations and publications:
Personal information collected on this form and appendices will be stored at the Paleo-DNA Laboratory
PROTECTED WHEN COMPLETED
Lakehead University – Paleo-DNA Laboratory – Application for Visiting Researcher Status
Page 3 of 3
REQUESTED DURATION OF VISITOR STATUS
Starting Date of Visit:
Final Date of Visit:
CONFIRMATION OF FINANCIAL SUPPORT
Please provide details specific to External Financial Support (including grant reference numbers, start date of funding, any special terms and
conditions related to external awards, and a total budget for this research to be conducted).
ATTACHMENTS (Attachments must be submitted with this application)
Letter of Support signed by Collaborator(s)
Curriculum Vitae of Applicant
Copy of Visa/Permit if applicable
SIGNATURES
______________________________
Visiting Researcher
_______________________
Date
______________________________
Collaborator(s)
_______________________
Date
Personal information collected on this form and appendices will be stored at the Paleo-DNA Laboratory
PROTECTED WHEN COMPLETED