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Application Form For Calum Muir Memorial Fellowship: PART 1 - General

This document contains an application form for the Calum Muir Memorial Fellowship. It requests information about the applicant's personal details, qualifications, experience, proposed fellowship project details, home and host institute approval, and cost estimates. The applicant must provide their CV, current job description, and a 300-word project description. Both the home and host institutes must approve the applicant and proposed fellowship dates.

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bahar yusuf
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61 views4 pages

Application Form For Calum Muir Memorial Fellowship: PART 1 - General

This document contains an application form for the Calum Muir Memorial Fellowship. It requests information about the applicant's personal details, qualifications, experience, proposed fellowship project details, home and host institute approval, and cost estimates. The applicant must provide their CV, current job description, and a 300-word project description. Both the home and host institutes must approve the applicant and proposed fellowship dates.

Uploaded by

bahar yusuf
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Date received (IACR use only) Application Nr (IACR use only)

IACR
APPLICATION FORM FOR
CALUM MUIR MEMORIAL FELLOWSHIP

PART 1 - General

Name of the Applicant:

Date of Birth: Nationality: Sex:

Present position: Since when:

Name of Department/Registry: Tel:

Fax:

E-mail:

Name and Title of Home Supervisor/Director: Tel:

Fax:

E-mail:

Name and Address of Home Institute: Tel:

Fax:

E-mail:

Name and Title of Host Supervisor/Director:

Name and Address of Host Institute: Tel:

Fax:

E-mail:

Language of Home Institute:

Language of Host Institute:

Title of Project Proposed during Fellowship:

Planned Date(s) of Visit: From: To:

Applicant’s Signature Date:


PART 2 - Additional Personal Information
(Professional Qualification and Experience)

Qualifications (Degree/Diploma) (Start Year received Institution/University


with very first)

1.

2.

3.

Previous Positions Name of Employers Years


(Start with most recent) worked

1.

2.

3.

Course activities/conferences attended on cancer registration in the last three years:

1.

2.

3.

Previous awards received, if any: Dates (Duration): Host Institute


Name of award

Supporting Documentation (see Guidelines) to be provided along with application:

1. Curriculum Vitae including recent publications

2. Summary of about 300 words of your present job description/responsibilities

3. Project Description:
A scientific/technical description of the work to be carried out during the Fellowship

Cost Estimates: Travel: Living Expenses:

I hereby declare that the foregoing statements are true to the best of my knowledge and that any
false statement will be sufficient cause for my application/fellowship to be rejected/cancelled. I
further state that if my application is successful, I shall return to my home institute at the end of the
fellowship.

Signature: Date:
PART 3 - Home Institute’s Release

Name and Title of Home Supervisor/Director:

Name and Address of Home Institute:


Tel:

Fax:

E-mail:

This certifies that:


Name of Applicant:

Working in Department/Registry:

is a suitable candidate for the proposed fellowship on


Title of Fellowship Project:

at Name
of Host Institute:

and he/she would be released in the event of the fellowship being awarded and permitted to rejoin
this institute on completion of the fellowship.

Home Supervisor’s Signature: Date:


PART 4 - Host Institute’s Support

Name and Title of Host Supervisor/Director:

Name and Address of Host Institute: Tel:

Fax:
E-mail:

This certifies that:


Name of Applicant:

Working in
Name of Home Institute:

will be carrying out the proposed fellowship on


Title of Fellowship Project:

Dates: Commencement Completion:

I have approved of the same and the relevant facilities would be made available for carrying out the
project successfully.

Host Supervisor’s Signature Date:

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