March 7, 2014
Re: Henry R. Shibata Cedars Cancer Fellowship
Dear Healthcare Professional,
You will find enclosed a hard-copy application form for the 2014 Henry R. Shibata Cedars Cancer
Fellowship and the Kate McGarrigle Fellowship in Sarcoma. However, please note that an on-line
version, that can be completed and sent by email to cedarsfellowships@muhc.mcgill.ca, can be
accessed through our website: http://www.cedars.ca/cedars/en/funds_and_fellowships/henry_shibata.
These grants are sponsored by the Cedars Cancer Institute and are designed to provide salary support to
either clinicians who wish to pursue additional fellowship level training in oncology abroad or to young
basic scientists initiating research at the MUHC. Successful candidates will be announced in the spring for
the awards which will be granted in the fall of the following academic year. Preference will be given to
those who are committed to continue their careers at the MUHC.
Please feel free to apply or pass this application on to any worthy applicants who may be interested in this
fellowship in oncology research.
Please mail or e-mail the following documents to the coordinates below.
1.
Original enclosed application
2.
Two (2) letters of recommendation one of which must be from your current supervisor, chair or
program director
3.
A letter from the applicant’s supervisor is required, confirming applicant’s acceptance and a critic
appraisal of the proposed project.
4.
Curriculum Vitae (12 copies only if mailed) – To include information on teaching and research
positions, list of publication, certificates, awards, scholarships, memberships etc…
5.
Eleven (11) copies of the original application (only if mailed), 1 copy if e-mailed.
The Cedars Cancer Institute
Henry R. Shibata Fellowship Award
c/o Mr. Jeff Shamie
2155 Guy St, Suite 900
Montreal, Quebec
H3R 2R9
or e-mail at
cedarsfellowships@muhc.mcgill.ca
For more information please see our website :
http://www.cedars.ca/cedars/en/funds_and_fellowships/henry_shibata
**ALL APPLICATIONS MUST BE TYPED**
The application deadline is April 30, 2014 .
With best personal regards,
Dr. Roger J Tabah, MD
Medical Advisory Committee, Chairman
HENRY R. SHIBATA CEDARS FELLOWSHIP
AWARD APPLICATION FORM
TITLE
FIRST NAME &
INITIAL
LAST NAME
PERMANENT ADDDRESS
CITY & PROVINCE
POSTAL CODE
HOME PHONE
WORK PHONE
ext.
SOCIAL INSURANCE
NO.
CELL PHONE
DATE OF BIRTH (yyyy/mm/dd)
TOPIC RESEARCH AREA:
SUPPORT REQUIRED FOR:
RESEARCH PURPOSES: ☐
CLINICAL TRAINING: ☐
The aim of the Henry R. Shibata Cedars Fellowship is to assist health professionals in their training and careers. If they
are meritorious and have not obtained funds from granting agencies or from other sources, they will be considered for a
FELLOWSHIP.
REQUIREMENT: At the end of the FELLOWSHIP, a brief summary of work accomplished and future goals should
be submitted to the Chairman of the Medical Advisory Committee
ACKNOWLEDGMENTS: Publications resulting from the efforts of the FELLOWSHIP should bear an
acknowledgement to the Cedars Cancer Institute of the McGill University Health Centre.
Amount Requested:
Signature:
Date:
The applicant is responsible for submission of a complete application (fully typed) prior to the April 30, 2014 deadline.
The complete application includes two (2) letters of recommendation (one of which must be from your current
supervisor, chair or program director), your curriculum vitae, the original application and (11) copies (if mailed) of the
application. Incomplete applications will not be considered.
1. FULL NAME OF APPLICANT :
2. PRESENT ADDRESS
PRIMARY TELEPHONE #:
FAX NUMBER:
EMAIL ADDRESS:
3. PRESENT APPOINTMENT:
4. ULTIMATE CAREER GOALS:
5.
EDUCATION
DEGREE:
UNIVERSITY:
DEGREE: :
UNIVERSITY:
6.
COURSE:
YEAR:
COURSE:C
YEAR:
EXPERIENCE
a)
ACADEMIC
DATES:
DEPARTMENT:
DATES:
DEPARTMENT:
POSITION:
INSTITUTION:
POSITION:
INSTITUTION:
b)
CLINICAL
DATES:
DEPARTMENT:
DATES:
DEPARTMENT:
POSITION:
INSTITUTION:
POSITION:
INSTITUTION:
c)
RESEARCH
DATES:
DEPARTMENT:
POSITION:
INSTITUTION:
DATES:
DEPARTMENT:
POSITION:
INSTITUTION:
7.
Teaching Experience: Small Group Teaching and Clinical Teaching:
8.
Distinctions and awards:
9.
Current interests or job development goals:
COURSE:
10. Membership in professional and scientific societies:
11. Publications: List papers published in the last five (5) years. Only full-fledged peer review journals are to be listed.
Give author, journal, page and year only; list abstracts separately:
12. Nature of proposed program:
13. Name other agencies to which application for personal support has or will be made:
14. Name of supervisor, department, location and contact information at which applicant has arranged to carry out
training/research:
15. A letter from the applicant’s supervisor is required, confirming applicant’s acceptance and a critical appraisal of
the proposed project.
16. Application to include letters of recommendation from two peers, one of which must be from applicant’s current
supervisor, chair or program director and the other from someone under whom the candidate has worked.
17. Recommendations
Recommendation #1:
NAME:
PRIMARY TEL.
, ext.
ADDRESS:
EMAIL:
Recommendation #2:
NAME:
PRIMARY TEL.
, ext.
ADDRESS:
EMAIL:
18. I certify that the information recorded herein is complete and accurate. I recognize that any falsified
documentation or evidence at the time, or subsequently found, will be basis for dismissal from the programme. I
hereby grant my permission to contact previous programme directors or any person/institution cited in this
application or appendices for further reference.
Dated at:
Signature:
this
day of
2014.
19. Approval of Department Head
Name of Department Head:
☐Yes
☐No
Signature of Department Head
Date:
(For office use only)
Cedars Cancer Institute Fellowship Application
Action of the Committee
Approved: ___________ Amount Recommended: $________________________
Not Approved: ________________________________________________________
Signature: ________________________
Date: __________________________
Print Name: __________________________________________________________