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tcdb sencanres prelim pt1

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IN CONFIDENCE

Please return to:
Dr Matthew Wakelin Science Operations & Funding Cancer Research UK PO Box 123 61 Lincoln’s Inn Fields London WC2A 3PX Email: matthew.wakelin@cancer.org.uk

Preliminary Application Form
Senior Cancer Research Fellowship Deadline: Friday 24th July 2009
Please complete this application form in full using the accompanying “Guidelines for application”. We regret that failure to complete any required section of the Application Form or to provide any requested accompanying information may result in your application being returned. For completion by the applicant: I confirm that I have:
Completed all sections of this application form Included an original (single-sided, unstapled with figures in colour as appropriate) E-mailed Parts 1& 2 of the application as two separate documents in a PDF format

Signature of Applicant

Date

We are currently reviewing the way that we advertise our schemes. We would be grateful if you would let us know how you found out about these fellowships:

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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PART 1 – APPLICATION FORM
SECTION 1

Application Summary

1.1 - Research proposal title

Applicant
1.2 - Full name & title

1.3 - Proposed Host Institution Details
Please Note: Applications will not be accepted unless a suitable host institution is identified.

Department Faculty / School Host Institution Address line 4 Address line 5 City/Town County Postcode Country

1.4 - Proposed Host Institution Negotiations
Please indicate the how far your negotiations with the proposed host institution have progressed:

Has your proposed institution already agreed to host the Fellowship if awarded? If NO, are discussions with the proposed institution ongoing?

Yes

No

If YES, please move onto Section 2

Yes

No

If YES, please indicate what stage your discussion has reached below

Please note that Cancer Research UK will not accept applications to work in an institution that is not already in discussion with the applicant.

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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SECTION 2

Research Proposal Outline
2.1 - Research project title
Please Note: Titles should be no longer than 185 characters long

2.2 - Proposed start date
(DD/MM/YYYY)

2.3 - Research goals
Please summarise the primary goals of your research in a format that can be understood by a non-specialist audience in no more than 50 words.

2.4 - Type of Application
New Application Revised Application

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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SECTION 2

Research Proposal Outline
2.5 - Research Proposal
Please complete your research outline below (continuing on additional pages as necessary). This should not exceed 1500 words (excluding references) and should be structured to give the (1) Background to the proposal; (2) Relevance to cancer; (3) Specific aims of the research; and (4) Outline plan of research. A full reference list, giving all authors and titles should be included.

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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SECTION 3

Applicant Details
3.1 – Applicant
Professional Title First Name Last Name Initials

3.2 - Contact Details
(for your current host institution)

Department Faculty / School Host Institution Address line 4 Address line 5 City/Town County Postcode Email Telephone Fax (if available) Research group/ Personal Website Address (if available) http:// Country

3.3 - Alternative Contact Details
(if applicable use this section to advise us of an alternative address where you may be contacted during the application process)

Full postal address

Email Telephone Fax

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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SECTION 4

Curriculum Vitae
4.1 - Qualifications
Most recent qualification first Date of qualification Title of qualification Awarding body

4.2 - Current post
Date of post
(start date – MM/YYYY)

Job title

Location †
(Group, Department & Institution)

Please detail your current responsibilities

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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4.3 - Previous positions held
Please list the most recent position first Date of post Job title
(start - end)

Location † (Group, Department & Institution)

4.4 - Research Experience
Please give brief details of your research experience to date, including when and where this took place.

†

For PhD/MD or postdoctoral posts, please give the name of the group leader

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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4.5 - Career Ambitions
Please give brief details of your career ambitions. You should include details of why you would like and believe you are suitable for the fellowship, the factors influencing your choice of host institution / research topic and what you hope to achieve as a result of the fellowship.

4.6 Clinical Details (only clinician-scientists need complete this section)
During your fellowship what percentage of your average week would you expect to spend on: NT Number (if applicable) Clinical discipline / speciality Please list your memberships of any of the Royal Colleges Please give brief details of your clinical training and experience to date (responsibilities, training undertaken etc) Clinical Sessions Research

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009

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4.7 - Publications
Please provide the total number of first author, last author and peer-reviewed publications First author publications Last author publications Peer-reviewed publications

Adhere to Medline/Pubmed conventions where possible Research Publications

Reviews

Cancer Research UK Senior Cancer Research Fellowship Preliminary Application 2009


				
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