Graduate Studies Awards Application Form

Fields denoted by an asterisk (*) are required.

Name Name First Last
Email
Student Number
Scholarships Awards

Scholarships Awards The Collip Medal Award Morris Kroll Memorial Scholarship Drs. Madge and Charles Macklin Fellowship for Publication Drs. Madge and Charles Macklin Fellowship for Teaching & Research Jonathan & Joshua Memorial Scholarship for travel ($1,400) Cobban Student Award in Heart and Stroke Research Norman E. Nixon and Marie Ramo Nixon Award The Jonathan & Joshua Memorial Graduate Scholarship in Mental Health Research ($25,000) Dean’s Research Scholarship (MSc, $10,000) Dean’s Research Scholarship (PhD, $14,000) Other

Please check all that apply. If your award is not listed, select 'Other' and specify the award name.
Please specify other award
Graduate information:
Graduate Program (select one)

Graduate Program (select one) Anatomy & Cell Biology Biochemistry Epidemiology & Biostatistics Microbiology & Immunology Medical Biophysics Path & Lab Medicine Physiology & Pharmacology Neuroscience Surgery Family Medicine (Phd) Other
Start Date Start Date / MM / DD YYYY

(in current degree)
Supervisor(s)

Include your Primary supervisor. If you do not know, or do not have one, indicate N/A.
Supervisor(s)

Only include if you are co-supervised
Citizenship
Are you a newly admitted student who would like the graduate office to use your reference letters?

Are you a newly admitted student who would like the graduate office to use your reference letters? Yes No

Newly admitted: means within the last 6 months
If you applied for a CGSM or CGSD, would you like the graduate office to use your application for these awards? (This includes your references and transcripts.)

If you applied for a CGSM or CGSD, would you like the graduate office to use your application for these awards? (This includes your references and transcripts.) Yes No

Please note: no changes can be made to these files. If you need to update your application, please fill out the entire form, including asking your references to adhere to the deadline.
Title of Thesis
Will this project be co-supervised by a clinician and a basic science researcher?

Will this project be co-supervised by a clinician and a basic science researcher? Yes No
Specify the role of each supervisor with regards to the project
Please explain in your own words, why you are the ideal candidate for this award:

[no more than a page is necessary/required]
Explain in your own words the rationale, hypothesis/objective, research plan and predicted significance of your research project (summary of research proposal):

[no more than a page is necessary/required]
Summarize all other demonstrated leadership, relevant life experience; teaching and community/volunteer work (include month and year):

[you must include month and year]
Academic Background (include all current and past degree programs with start and end dates):
List all Scholarships and other awards held or offered. Example: Ontario Graduate Scholarship (held 2009 - 2010), value $15,000

[include all awards, the amount and years offered/awarded]
List all academic, research and other relevant work experience (include start and end dates)

[including summer research experience]
Productivity (Please include your publications, abstracts, and presentations in the formats specified below.)
Please follow the format below when listing publications, abstracts, and meeting presentations. Copy and paste each citation from your CV into the appropriate document box in the PRODUCTIVITY TEXT BOX (above text box)

For publications, include all authors in proper order, the complete title, journal name, page numbers, and year of publication. Additionally, provide the latest available journal impact factor, citation numbers, and your h-index (if applicable). You must also include a brief (3-4 line) description of your role in the research and publication process.

For abstracts and presentations, a role description is not required.
Formatting examples:

Publication:
Calder, M.D., Watson, P.H., & Watson, A.J. (2011). Culture medium, gas atmosphere, and MAPK inhibition affect regulation of RNA-binding protein (RPB) targets during mouse preimplantation development. *Reproduction, 142*, 689-698. Impact Factor: 3.555. My role: Assisted with study design, research result analysis, paper drafting and submission, and securing grant funding.

Abstract:
Bell, C.E., & Watson, A.J. (2009). The expression of transcription factors SNAI1 and SNAI2 throughout preimplantation development. *Biol Reprod, Sp*, p101.

Presentation:
From Zygote to Blastocyst: How We Made It? *22nd UCLA Symposium on In Vitro Fertilization and Assisted Reproductive Technologies*, Santa Barbara, California, July 12-14, 2009.
Referee Information

Please have your referee send their references by the deadline date specified in the application directly to Janelle Pritchard at jpritch7@uwo.ca
Referee #1 Name
Referee #1 Title
Referee #2 Name
Referee #2 Title

Graduate Studies Awards Application Form

Graduate Studies Awards Application Form

Graduate information:

Referee Information