Interdisciplinary Fellowship Program
2016 Cohort – 1 Year Program
Application Signatures Form
Please save this form as “IFP2016-##_Surname_Signatures” (NB: ## = assigned TVN File #;
Surname=Applicant’s surname). Refer to Application Instructions.
Fellowship Applicant
Last
Name
First
Name
I wish to be added to the TVN mailing list (notification of funding opportunities, Network changes, etc.).
I, the undersigned, having read the TVN 2016 Interdisciplinary Fellowship Program Guidelines and Overview of
Deliverables, Roles and Responsibilities, and completed the Applicant & Supervisor Capacity Disclosure form
am aware of my responsibilities under the Fellowship Program, and have the time and resources required to
fulfill these responsibilities.
I also declare that I have provided true, complete and accurate information in all aspects of my application
package. I understand that TVN has the right to reject an application or retract the award of a fellowship on
the basis of false or misleading information forming any part of a TVN Interdisciplinary Fellowship application.
If any circumstances pertaining to this application change, including other funding or my capacity to
successfully complete the Fellowship, I agree that I will advise the TVN Executive Director immediately.
Fellow’s Signature
Date
Fellowship Supervisor
Last
Name
First
Name
I wish to be added to the TVN mailing list (notification of funding opportunities, Network changes, etc.).
I, the undersigned, having read the TVN 2016 Interdisciplinary Fellowship Program Guidelines, Overview
(Abbreviated) of Supervisory Role, Overview of Deliverables, Roles and Responsibilities, and Applicant &
Supervisor Capacity Disclosure form declare that to the best of my knowledge the applicant meets the
eligibility guidelines, that I am aware of my responsibilities under the Fellowship Program and that I have the
time and resources required to fulfill these responsibilities.
I understand and acknowledge that I will be required to obtain all ethics approvals and/or environmental
assessments required pertaining to the fellowship applicant’s work, that funding will go to my host institution,
and that to receive funding I and my institution must be eligible to receive funding under Tri-Council
Guidelines, and must enter into a TVN Network Agreement and agree to administer the Fellowship as per TriCouncil and TVN Terms and Conditions. Specifically, I understand and acknowledge that the fellow I am
supervising must complete all deliverables in order for funding to be released to my institution.
I declare that I have provided true, complete and accurate information in all aspects of my application, and
that to the best of my knowledge the applicant has also been truthful in the documents submitted as part of
the application. I understand that TVN has the right to reject an application or retract the award of a
fellowship on the basis of false or misleading information forming any part of a TVN Interdisciplinary
Fellowship application. If any circumstances pertaining to this application change, including other funding or
the applicant’s or my capacity to successfully complete the Fellowship, I agree that I will immediately advise
the TVN Executive Director.
Supervisor’s Signature
Date
Host Institution of the Fellowship Supervisor Named Above
Last
Name
First
Name
Institution
I, the undersigned, acknowledge that the Institution named above is aware that the fellowship applicant and
supervisor named above have applied for funding from Technology Evaluation in the Elderly Network (TVN), a
national research network funded by Industry Canada and Health Canada through the Networks of Centres of
Excellence (NCE) program.
Signature
Date
Vice-President, Research, of the Institution named above
(or authorized delegate)
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