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UJdN3mqkH6fRy7TUIwmdt8sdzXai6sxxJMoWPu8Bv4sx3NPoV

Surgeon Scientist Training Program Application

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DEADLINE: May 15th

To complete this form you will need signatures and information from both the trainee and supervisor. To send this form to a supervisor for a signature or other information, scroll to the bottom and click "Save". You will be prompted to sign-up for a free JotForm account which will allow you to continue completing this form at a later date, as well as get a shareable link to this form that you can send to your supervisor for their signature/content.

First Name of Trainee:

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Last Name of Trainee:

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Program:

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Research start date:

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Copy of Trainee CV:

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Name of proposed supervisor who has agreed to act as your supervisor:

Name of external agency to whom you have applied for funding:

Name of Institute/Graduate Department to which you have applied or will apply for admission as a graduate student in the School of Graduate Studies (it is the responsibility of the student to complete this application process prior to starting date of research):

Letter of support from Division Program Director:

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Name of University Division Chair with whom you have discussed this application and whom you have asked to forward a letter of support:

Letter of support from University Division Chair:

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Why do you wish to join the Surgeon Scientist Training Program?

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Description of research to be performed:

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Trainee's Signature:

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University DIVISION Head Signature:

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Name of proposed trainee:

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Trainee research start date:

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Name of proposed supervisor:

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Branch of graduate school in which you are a member:

Supervisor's current grants:

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Location of proposed research:

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Proposed source(s) of personal salary support for surgeon scientist trainee:

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Description of research to be performed by trainee:

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Supervisor's Signature:

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Trainee's Name:

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Supervisor's Name:

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Lab Address:

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Lab Phone Number:

Completed Application Sections (Please check boxes if completed)

If any documents are missing from this online application, please make a note below and send when available to:

Michael G. Fehlings, Vice Chair Research
c/o Research Program Coordinator
Department of Surgery Research Office, University of Toronto, Stewart Building
149 College Street, 5th Floor, Room 503J Toronto, ON Canada M5T 1P5
tel: 416-978-8909
fax: 416-978-3928
email: research.surgery@utoronto.ca

Part 1: Trainee Application

Trainee CV

Letter of Support from Division Program Director

Letter of Support from University Division Chair

Part 2: Supervisor Application

Part 3: New Surgeon Scientist Contact Information

Clinician Investigator Program Application (deadline January 15th for enrolment in September) - Sent to CIP Office (c/o CIP Office, Faculty of Medicine, University of Toronto, Ste. 2366 Medical Sciences Bldg., Toronto M5S 1A8)

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