CUA – Canadian Urological Association
Become a CUA Member
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CUA Astellas Research Grant
Name (in full)
Date of birth
CUA Membership Number
Telephone # work
Telephone # home
Location of Residency Training
Year of Residency
Name of Institution and Department where applicant will conduct his/her academic/research activities
Academic Rank to be held by the applicant during tenure of the research
Name, address and telephone number of the Department/Division Chair person
Name of Supervisor of Research Project
Type of Research (eg. Clinical, translational, interventional, basic research, genetic studies, epidemiology, health outcomes, and quality of life studies)
Research Experience (a brief description of work in which the applicant has participated)
Briefly describe the environment and the research facilities
Briefly describe your long term career plans and research objectives and how this project will impact these objectives
Name of Applicant
Research Proposal not exceeding five (5) single spaced, typewritten pages (Please refer to “Guidelines for Application Submission” in the Terms of Reference for suggested headings)
Summary of the research proposal not exceeding one (1) single spaced, typewritten page
Curriculum Vitae (Please submit a pdf version of your Common (CIHR) CV)
Letter outlining the clinical and/or research plan for fellowship not exceeding (5) single-spaced pages (please see suggested headings in Terms of Reference)
A maximum of three (3) published reprints or pre-prints (if applicable)
Letter of support from the Department/Division Chair supporting this application and agreeing to conform to the Terms of Reference. The letter should indicate the level of support and commitment by the university/institution for the candidate.
Name and contact information for three (3) external reviewers
Two (2) additional letters of recommendation, one (1) of which should come from an individual not associated with the Institution where the proposed research will take place.
Evidence of appropriate Ethics Committee approval or application for approval must be included along with the consent forms where human subjects are involved in the study.
In addition to the items listed above, renewal applications must include a progress report.
Application has been submitted successfully