Page 3 - CUA-Tolmar CPD Grant

CUA-Tolmar Community Urologist

Continuing Professional Development (CPD) Grant Program

APPLICATION FORM

SECTION 1 – CONTACT INFO

CUA Membership Number:

Name (in full):

Date of birth (YY/MM/DD): Citizenship:

Mailing Address:

Email Address:

Tel. # (work): Tel. # (home): Tel. # (fax):

SECTION 2 – PROPOSAL

Title of Proposed CPD Initiative:
Brief Description & Justif cation of Proposed CPD Initiative:

SECTION 3 – AUTHORIZATION
By submitting this application, I agree to respect and follow the regulations that govern this Award, should it
be successful.
Date (YY/MM/DD): Place:

Name of Applicant:

APPLICATION CHECKLIST

1) A letter of intent, not exceeding one (1) page, outlining the proposed CPD initiative
and how the CPD activity meets the objective of the grant
2) A budget, including detailed list of source(s) for matched funding

3) Curriculum Vitae (Please submit a pdf version of your Common (CHIR) CV)

All applications should be emailed to: Canadian Urological Association
Girish Kulkarni, MD, FRCS(C), Chair, CPD Committee, CUA 185 Dorval Avenue, Suite 401
c/o Tal Erdman Dorval, Quebec, Canada H9S 5J9
tal.erdman@cua.org Tel: (514) 395-0376 Fax: (514) 395-1664