APPLICATION FORM FOR LEADERSHIP PROGRAMME CALL 3 (2014/15)

InstructionsBefore you complete this application form you should:

Read the Terms of Reference carefully (available at www.cardi.ie) Talk to your mentor or head of department in your Higher Education Institution (HEI) Read through the form so that you know what it covers Note that there are up to four Fellowships and specific requirements for the two Beeson-sponsored

CARDI Fellowships; complete your answers accordingly.

This application form has three sections:

1. Your potential as a future leader in ageing research2. Proposed research topic3. Career development plan

NominationYou must be nominated by a university in Ireland, north or south. The head of department (or equivalent) or mentor will send CARDI a separate statement supporting you. Information about the contents of the statement is available at www.cardi.ie. The HEI statement will form part of the assessment process.

Font and spacing Please use Arial font 11 point and 1.15 spacing (as in this set of instructions); if your version of Word does not support 1.15 spacing, use single spacing.

Word countYou must adhere strictly to any word count specified for your answers. Words above the word count will be deleted before the application form is sent to assessors.

QueriesIf you have difficulty completing any part of this form or need clarification on any point, you are welcome to email leadership@cardi.ie. Questions and replies will be put on the CARDI website.

DeadlineThe completed application form and the statement from your nominating HEI must be returned to CARDI before 12.00 noon on Friday 30 January 2015. They should be emailed to leadership@cardi.ie or posted to CARDI, Forestview, Purdy’s Lane, Belfast BT8 7ZX.

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Applicant name:

ID No:

Section 1: Leadership Qualities

Applicant’s Details

Title:Full Name:Address:

Work Telephone:Mobile:Email Address:Present HEI (Higher Education Institute)Are you a European Union Citizen YES NO

Qualifications

Dates:Month/Year

University Degree TitleFull Name of Degree Course

Grade

Doctorate

Date awarded:Title of Degree:Nature of Degree (tick): By Research: Taught: Title of Research topic:

Name of Supervisor

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Employment HistoryDates Name and Address of Employer Position Held and Brief Description of Duties

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Research ProjectsPlease give details of all relevant research projects you have been involved in*

Research Project 1

Research topicHEI/Other organisationPrincipal investigatorFunding body and amountDate commencedDate completedExplain your contribution to the researchSpecify your contribution to the outputs from the project e.g. report, journal article, other

Research Project 2

Research topicHEI/Other organisationPrincipal investigatorFunding body and amountDate commencedDate completedExplain your contribution to the researchSpecify your contribution to the outputs from the project e.g. report, journal article, other

Research Project 3

Research topicHEI/Other organisationPrincipal investigatorFunding body and amountDate commencedDate completedExplain your contribution to the researchSpecify your contribution to the outputs from the project e.g. report, journal article, other

*If you have been involved in more than three projects, please copy and paste additional copies of this table.

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Research Outputs and Achievements Part 1Please list your journal articles, published reports, book chapters and books, with full citations. In the case of research outputs you have contributed to, specify your contribution.

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Research Outputs and Achievements Part 2Please list all other outputs e.g. presentations, posters or knowledge translation activities, with full citations. In the case of outputs you have contributed to, specify your contribution.

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Research FundingPlease provide details on any funding you have secured from any source (list)

Honours or Awards GainedPlease provide details on any honours or awards you have gained (list)

MembershipsPlease provide details on any research networks you are a member of (list)

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Potential for Research LeadershipPlease explain how your experience and expertise demonstrate that you have the potential to be a research leader in ageing research (max 250 words)

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Section 2: Research Topic Proposed

Title of Research:

How does your proposed research topic relate to the needs of an ageing population? (max 250 words)

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Aims and objectives of research project (max 500 words)

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Summary literature review (max 500 words)

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Methodology (max 500 words)

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Timeline and milestones (max 250 words)

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Proposed Outputs (max 250 words)

Ethical StandardsDoes this proposal need ethical approval (tick)? Yes No

Have you applied for ethical approval (tick)? Yes No

Additional information in support of your application for a CARDI Fellowship or a Beeson-sponsored 14

CARDI Fellowship (please do not repeat information already given) (max 250 words)

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Please indicate present salary (specify € or £):

Please indicate present scale

List of Research Costs (specify € or £)1

Description Year 1 Year 2 Year 3 CARDI Contribution Other Contribution

Total Cost

SalaryResearch costs e.g. research assistant, data cleaningConference feesTravel and subsistenceOther costs (please specify)TOTAL (specify € or £)

1 CARDI will specify a conversion rate for euros and British pounds in the letter of offer to successful candidates. It will also specify conversion rates for US$ in the case of Beeson-sponsored CARDI Fellows. 16

Section 3 – Career Development Plan

Applicant’s Host HEI (Higher Educational Institution)

What are your career goals for the next five years and the next ten years (max 250 words)

How will your proposed research project contribute to these goals? (max 400 words)

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What training do you need to achieve your goals and how do you propose they are met? (max 250 words)

What support and mentoring do you need to achieve your goals? (max 250 words)

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Who is your internal mentor in the Higher Education Institution?Name:Title:Position:Do you have additional mentors in your HEI or elsewhere?Name:Title:Position:HEI name:

What do you expect your mentor(s) to offer you over the next three years? (max 250 words)

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How will you best use a CARDI Fellowship to achieve your career goals? (max 250 words)

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Declaration and Signatures

In submitting this proposal, I confirm that:I have read and understood the terms of reference and confirm that the application complies with these.I have not entered into any obligation which may conflict with the terms of reference.

Name in BLOCK CAPITALS Signature DateApplicant

Internal mentor or head of department

Institution/Finance Department administering the grantInstitutionAddress

PostcodeTelephone numberEmail addressName of designated officer

Position of designated officer

Signature of designated officer

The completed application form and the statement from your nominating HEI must be returned to CARDI before 12.00 noon on Friday 30 January 2015. They can be emailed to leadership@cardi.ie or posted to CARDI, Forestview, Purdy’s Lane, Belfast BT8 7ZX.

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