Application for post-doctoral or clinical research fellowship
(Application deadline : January 15 of each year)

Fill and print this form (must be in 11 copies).
To print the form, first click on the "View" button at the bottom of this page.
And then on next page, use the print button from your browser.

1. Sex  M   F  
2. Name
3. First name
4. Date of birth (MM/DD/YY)  /  / 
5. Place of birth
6. Citizenship
7. Resident in Canada since
8. Adress, phone number and e-mail

Research project
References
Other awards

9. Degree Year University Subject
 
 
 


10. Title of the proposed research and name of the supervisor


11. List past positions (include the post-doctoral years of formation)

Position Year University

12. Research grant and academic distinctions

13. List of your publications (including memory and / or thesis if necessary)







Research project (in 400 words or less)
Describe the research project that you are planning including the techniques and expertise that you wish to acquire during this post-doctoral or clinical research year. Note that the project must be related to the field of epileptology.


References
Give the name of two individuals whom you have asked to forward letters of recommendation directly to the foundation. Please ask the director of the laboratory where your research will be conducted to send separately, a letter of evaluation and acceptation of your research project.
* (You have to make sure that the letters will be received before January 15)


Other awards
Other awards already received or applied for. (Give agency, amount and period)

 

Signatures


Applicant
Head of Department
Principal or Dean