Fellowship Application | Molly Towell Perinatal Research Foundation

1 Applicant Information

2 Funds & Research Related Questions

3 References & Signature Files Upload

4 Confirmation & Submission

Applicant Information
Name*
First Last
Email*
Phone*
Fax
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Curriculum Vitae*
Please append curriculum vitae outlining your educational achievements, academic experience, any previous research experience and a publication list. (File formats allowed are pdf, doc, docx, xls and xlsx.)
Accepted file types: pdf, doc, docx, xls, xlsx.

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Funds Related Questions
Total amount requested per year*
For how many years*
Please enter the number of years
Is sponsoring/host institution providing matching funds?*
- Yes
- No
Host Institution
Name of the officer who will administer funds*
First Last
Title of the officer who will administer funds*
Please provide the name of the institution to which the cheque should be issued.*
Research Related Questions
Research Mentor's Name*
First Last
Research Mentor's Title*
Affiliation*
Please upload the signature file of your research mentor. (File formats allowed are pdf, jpg, png and gif)*
Download Signature form here.
Accepted file types: pdf, jpg, png, gif.
Proposed Research Training: please append a description of the research training you intend to undertake during your fellowship. (File formats allowed are pdf, doc, docx, xls, xlsx, ppt and pptx)*
1 page maximum describing training goals, the setting and how this training will contribute to your scientific career.
Accepted file types: pdf, doc, docx, xls, xlsx, ppt, pptx.
Proposed Research: please append a description of your proposed research, why you have chosen the proposed mentor and your career aspirations. (File formats allowed are pdf, doc, docx, xls, xlsx, ppt and pptx.)*
2 page maximum exclusive of reference, tables and/or figures; font size 12; one-inch margins.
Drop files here or

Accepted file types: pdf, doc, docx, xls, xlsx, pptx, ppt.

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Letter of Reference
Please provide the names of three individuals, preferably including your current department head, who have been asked to provide a letter of reference on your behalf. The proposed mentor must be one of the three. The letters of reference should highlight the candidate's strengths as they relate to suitability for research (e.g. creativity, technical aptitude, critical skills and judgement). The three letters of reference should be confidential and each letter sent directly from the referencee to admin@mtprf.org on or before April 20, 2018.
Reference 1
Name*
First Last
Email*
Institution Name*
Reference 2
Name*
First Last
Email*
Institution Name*
Reference 3
Name*
First Last
Email*
Institution Name*
Signature Files
Please upload the signature file of your head of department and Institution. (File formats allowed are pdf, png, jpg and gif.)*
Download Signature form here.
Accepted file types: pdf, png, jpg, gif.
Please upload your signature file. (File formats allowed are pdf, png, jpg and gif.)*
Download Signature form here.
Accepted file types: pdf, png, jpg, gif.
Use of Information*
In consideration for the Molly Towell Perinatal Research Foundation (the Foundation), accepting this application for funding, I consent to the use my personal and research information within this application for the purposes of evaluating the merits of the funding request, and to make this information available to the adjudication committee members, including the members of the Foundation Board, and its administrator. Should I receive funding, the Foundation is permitted to post information regarding my name, and affiliations, as well as an extract describing the funding amount, and the nature of my intended use of the funding. During and upon completion of the funding time frame, public disclosures may me made regarding progress, and outcomes resulting from the funding.
- Yes, I agree to the above Use Of Information

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Email
This field is for validation purposes and should be left unchanged.

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Applicant Information

Funds Related Questions

Host Institution

Research Related Questions

Letter of Reference

Reference 1

Reference 2

Reference 3

Signature Files