Dr Albert S McKern Travelling Research Scholarship Application

Dr Albert S McKern Travelling Research Scholarship
Application form 2016 (to commence in Semester 1 2017)
(Note: this Scholarship is only available to graduates of University of Sydney,
Australia; University of Edinburgh, Scotland; Yale University, USA)
Discipline of Obstetrics, Gynaecology and Neonatology
Opening date: 6 June 2016
Closing date: 12 August 2016, 12:00pm midday
Notification date: 24 October 2016
Late applications will NOT be accepted
Please email your completed application and attachments to:
Burcu Karlsson
Obstetrics, Gynaecology & Neonatology Discipline Support Officer/Sydney Medical School-Northern
Email: [email protected]
1. PERSONAL DETAILS
Family Name:
Other Names:
Contact Address:
Title:
Student No:
Contact Telephone Number/s:
Email:
2. Please complete (a) or (b)
(a) CURRENT ENROLMENT DETAILS
Department / School:
Degree:
Attendance:
PhD
Masters by research
Full-time
Part-time
Number of full-time equivalent (FTE) semester/s you are enrolled in this course (including any upgrade
from a Masters by research to PhD) at the closing date for applications:
______ FTE semester/s since __________/__________ (month and year)
Name of your Supervisor:
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(b) CURRENT POSITION DETAILS
Department/School:
Title:
Full-time
Part-time
3. SCHOLARSHIP/S CURRENTLY HELD
Name of Award (list all scholarships currently held):
Commenced from:
(month and year)
Value of Award:
4. FUNDING SOUGHT: Please attach a budget including quotes indicating the total
amount requested and a breakdown via category such as travel, accommodation, etc.
Please insert amounts per category here (additional information to be provided in Amount:
attachment)
5. HAVE YOU PREVIOUSLY RECEIVED A DR ALBERT S MCKERN
TRAVELLING OR RESEARCH SCHOLARSHIP?
Yes
No
If the answer to the above is “Yes” please provide details
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6.
ACHIEVEMENTS RELATED TO RESEARCH (IF ANY):
Please attach a 2 page CV summarising research experience and achievements
List details of any prizes, seminars, conference presentations/posters, publications (state
whether published, in press or submitted only) and internal reports that have resulted from your
research to date. Attach a separate sheet if required.
7. SUPERVISOR’S SUPPORT (STUDENT)
I support the application for funds by the applicant who is undertaking a PhD/Masters by research
degree under my supervision. (Additional comments should be made on a separate sheet and
attached to the application.)
Signature of Supervisor: …………………………………………………. Date: ……………………..……
8. HEAD OF DEPARTMENT SUPPORT (ALL APPLICATIONS OTHER
THAN STUDENT)
I support the application for funds by the applicant who is undertaking investigations into the cause,
prevention and treatment of mental and physical pain and distress during pregnancy, labour and
puerperium.
Signature of Head of Department: …………………………………………. Date: ……………..…….
9. APPLICANT’S SIGNATURE
I have read and checked the eligibility criteria in the Terms and Conditions. I declare that the
information provided by me on this application form and supporting documentation is complete, true
and correct.
Signature of Applicant: ……………………………………………………… Date: ………………..…….
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