Postgraduate Programs

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FELLOWSHIP APPLICATION

for the

POSTDOCTORAL TRAINING PROGRAM IN CLINICAL MICROBIOLOGY

Part I: General Information

Name:

Current Address:

Permanent Address:

Telephone Number(s):

E-mail:

Current Occupation or Status:

Citizenship Status:* Canadian Citizen Permanent Resident

*Please Note that only those with Canadian citizenship or permanent residency status in Canada are eligible for the Ontario Ministry of Health Fellowship attached to this training program.

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 Microbiology Program, Department of Laboratory Medicine & Pathobiology, University of Toronto

Postdoctoral Training Program in Clinical Microbiology – Application Form Part II

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Part II: Educational Background and Experience

University Institution and

Dates Education Field of

Specialization Year Degree Awarded

Predoctoral experience relevant to Clinical Microbiology, Clinical Chemistry, Hematology, or Molecular Biology (List employers, type of position, dates)

Postdoctoral experience relevant to Clinical Microbiology, Clinical Chemistry, Hematology, 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.

Postdoctoral Training Program in Clinical Microbiology – Application Form Part III

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Part III: Personal Statement and References Describe concisely in the space below your reasons for seeking to qualify as a professional Clinical Microbiologist.

Give names, titles and mailing addresses of three referees whom you have asked to write in support of your application. 1

2

3

Postdoctoral Training Program in Clinical Microbiology – Application Form Part IVa

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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 by email to:

Department of Laboratory Medicine and PathobiologyUniversity of TorontoMedical Sciences Building, Room 6231Toronto, ON M5G 1A8Email: pathology.residency@utoronto.ca

Postdoctoral Training Program in Clinical Microbiology – Application Form Part IVb

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Part IVb: 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 Average

Average Below Average

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 assessment that you feel would be helpful to those evaluating the candidate.

Date: Position,

Department:

Signature of Referee:

Address:

Print Name:

Note: This form and your letter are to be forwarded directly to the Program Director of the Clinical Microbiology training program.