Postgraduate Programs

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1 Postgraduate Programs FELLOWSHIP APPLICATION for the POSTDOCTORAL TRAINING PROGRAM IN CLINICAL CHEMISTRY including training in related clinical laboratory disciplines Part I: General Information Name: Current Address: Permanent Address: Telephone Number(s): Current Occupation or Status: Citizenship Status:* Canadian Citizen Permanent Resident *Please Note that only those with Canadian citizenship, permanent residency status in Canada or landed immigrant status in Canada are eligible for the Ontario Ministry of Health Fellowship attached to this training program. Are you willing to accept a commitment to return service in Ontario for a period equal to the duration of this Fellowship? Yes No Date Signature of candidate By signing this form I agree to the distribution of the information contained herein only for the purposes of application to the Clinical Chemistry Program, Department of Laboratory Medicine & Pathobiology, University of Toronto LMP updated: 14-Nov-12 Page 1 of 5

2 Postdoctoral Training Program in Clinical Chemistry Application Form Part II Part II: Educational Background and Experience University Institution and Dates Education Field of Specialization Year Degree Awarded Predoctoral experience relevant to Clinical Chemistry, Hematology, Microbiology, or Molecular Biology (List employers, type of position, dates) Postdoctoral experience relevant to Clinical Chemistry, Hematology, Microbiology, or Molecular Biology (List appointments held, research or other activities, dates) List (a) Papers and (b) Abstracts you have published (Titles, references, co-authors, if any). Enclose available reprints. Attach extra sheet if necessary. Page 2 of 5

3 Postdoctoral Training Program in Clinical Chemistry Application Form Part III Part III: Personal Statement and References Describe concisely in the space below your reasons for seeking to qualify as a professional Clinical Chemist. Give names, titles and mailing addresses of three referees whom you have asked to write in support of your application Page 3 of 5

4 Postdoctoral Training Program in Clinical Chemistry Application Form Part IVa Part IV: Confidential Assessment by Referee Section A (to be completed by Applicant) Candidate s Name and Address Prime reasons for undertaking this Program: Please send reference letters and the completed form on the next page to: Khosrow Adeli, PhD, FCACB, DABCC Program Director, Postdoctoral Training Program in Clinical Chemistry c/o Department of Laboratory Medicine and Pathobiology University of Toronto Medical Science Building, Room King's College Circle Toronto, ON M5S 1A8 Page 4 of 5

5 Postdoctoral Training Program in Clinical Chemistry Application Form Part IVb Part IV (cont d): Confidential Assessment by Referee Section B Completed by Referee How long and in what capacity have you known the candidate? Please give your assessment of the academic or capability rank of the candidate relative to others you have observed in the same situation: Upper 10% Upper 20% Upper 30% None of these Please describe the applicant, under those headings you feel you can evaluate, by a check in the box that represents your judgement of his/her skills. Outstanding Excellent Above Below No basis for sound judgment Background Preparation Intellectual Ability Analytical & Technical Skills Industry/Perseverance Motivation/Initiative Organizational Ability Research Ability/Originaltiy Teaching Ability/Positivity Judgment/Maturity/Critical Sense Verbal Communication/Writing Skills Personality and Interpersonal Skills Character Please write a letter of reference for the candidate, amplifying or qualifying any aspect of your Reset Form assessment that you feel would be helpful to those evaluating the candidate. Position, Department: Date: Signature of Referee: Address: Print Name: Note: This form and your letter are to be forwarded directly to the Program Director of the Clinical Chemistry training program (see page 4a). Save As LMP updated: 14-Nov-12 Print Page 5 of 5

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