COLLEGE OF DENTISTRY (COD) ENDOWMENT FUND APPLICATION FORM

COLLEGE OF DENTISTRY (COD) ENDOWMENT FUND
APPLICATION FORM
PERSONAL INFORMATION
NAME(S):
(please print)
Please √ :
_____ New College Member
DEPT(S)
YEAR, IF STUDENT
(Graduate & Undergraduate)
_____ First-Time Applicant
_____Repeat Applicant
(within 2 years of appt.)
Please note that priority will be given to first-time applicants to the Endowment Fund. Priority will also be given to requests to support sound graduate student
research proposals. If you have been a recent recipient (within the last 2 years) we kindly ask that you consider the need for your request. Research applications
for novel studies that would generate pilot data to assist with applications for funding at the provincial or national level will also be given priority. Faculty with
start-up funds are strongly encouraged to rely on those funds prior to applying to this fund as a principal applicant.
APPLICATION INFORMATION
NOTE: Student Scholarships and financial assistance are not supported by the Endowment Fund.
TITLE OF PROJECT/REQUEST:
Please √ :
1. Research: a) Clinical/practice-based ___ b) Basic Science ___
2. ___ Education/Scholarly
3. ___ Health Promotion
4. ___ Other Projects/Programs/Outreach
Use of Funds (√): _____
_____
Equipment / Supplies
_____ Pilot Data Collection
Research support personnel Salaries Other: ______________________________________
(Note: Research Funds are not available for travel)
Please Note: Applications will be assessed on their scientific/scholarly merit
ADDITIONAL INFORMATION – REQUIRED FOR ALL APPLICATIONS
Maximum of 3 additional pages (single spaced) Applications Submissions must be completed in full.
Information will be used to prioritize applications.
Please provide the following details regarding your application:
 Background literature supporting the application OR describing the rationale or situation which necessitates the application.
 Budget information with supporting details of the requested equipment/supplies/activity. Quotes for services, materials are
required.
 Alternative sources of funding and the minimum amount of funding below which this project could not be undertaken, must
be provided.
 Each application must include an account of progress/publications arising from projects supported by the Endowment Fund
during the last three years (even if the previous funding was for different projects). Do not just list conference presentations.
The application will not be considered if this information is not provided.
FUNDING REQUESTED
Have you sought external /other funding for this project?
_____ Yes
_____ No
If yes, was funding granted?
_____ Yes
_____ No
If yes, what was the total amount of funding received $ ___________________
Total external research funding presently held by the applicant(s) or supervisor
Do you have start-up funds?
_____ Yes _____ No
If yes, are you able to use your start-up funds to fund this project? ______________
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If no, why not? ____________________
Budget Summary:
Salaries for staff (not applicants)
Equipment
Supplies
Other (specify)
$
$
$
$
Total
Please note:
_____________
_____________
_____________
_____________
$ _____________
All funds allocated must be spent within 6 months of receipt of award OR within 12 months with permission
from the committee. Funds not spent will revert back to the control of the Endowment Fund Committee.
APPLICATION PROCEDURES
 Please submit the original and fourteen (14) copies of this Application Form and Additional Information to the Endowment
Fund Committee C/O Dawn Silva, Student Services – D028, College of Dentistry by Friday, January 9, 2015.
Date: ________________
Signature(s): ________________________________________________
Please note that by signing this application, the applicant agrees to, in the event of winning an endowment, give authorization to the College of
Dentistry to publish his/her name in a College of Dentistry brochure and post it on the College’s website (www.umanitoba.ca/dentistry) for the
purpose of public distribution. Photos of the winners may also be taken and published for this purpose, and the applicant, upon winning an
endowment, waives any right to inspect or approve the finished photographs, videos, advertising copy, or printed matter that may be used in
conjunction therewith or to the eventual use that might be applied.
IF YOU HAVE ANY QUESTIONS REGARDING COMPLETION OF THIS APPLICATION – PLEASE CONTACT DAWN SILVA@
[email protected]
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