learn and
see the country
Fellowship Application
Use the English or the French application but questions 10, 11, 12 and 14 must be completed in both languages.
1.
host University
University
of Calgary
Université
Laval
Université
de Montréal
University
of Western Ontario
To which faculty/school have you been accepted?
Indicate your proposed program of study
Indicate your proposed degree
Proposed program
start date
September
year
January
May
Note that certain programs
commence only in September
2. Personal Information
Ms
Mr
surname
given name(s)
Place & province of birth
Canadian Citizenship?
*Only Canadian Citizens are eligible.
No
mailing address (Please notify the Foundation of any address change)
apt.
street
city
province
country
postal code
email
daytime phone
evening phone
I, the undersigned, hereby certify that the information provided on this form is accurate and complete, and that I consent to the use of this
information by the Schmeelk Canada Foundation and the University to which I am applying.
Signature
Date
Year month
day
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schmeelk-en-v6 - 20110208
3.
Yes
4.
permanent address
apt.
Tick here if same as mailing address
street
city
province
country
postal code
5. language proficiency (Tick all appropriate boxes)
Mother
TONgue
language
Current
Primary
Language
listen
read
speak
English
French
Other _____________________
Other _____________________
6.
education
Name your secondary school(s) and CEGEP (if applicable).
Secondary School(s)
Place &
Province
Teaching Language
CEGEP
Place &
Province
Teaching Language
Name all post-secondary institutions attended and provide details in the fields provided.
Applicant must submit original official university transcripts.
#1
#2
university/college
address
from
#3
university/college
address
to
from
diploma/degree obtained
diploma/degree obtained
major
major
#4
university/college
address
from
university/college
address
to
from
diploma/degree obtained
diploma/degree obtained
major
major
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to
to
write
7.
academic awards & distinctions
(List in reverse chronological order)
8.
publications
(List in reverse chronological order)
9. current employment
employer
size of organization
address
title
nature of business
main responsibilities
number of years position held
number of years at employer
10. work experience
#1
#3
from
to
#2
from
employer
employer
position
position
from
to
#4
from
employer
employer
position
position
to
to
Please explain, in English and in French, any career interruptions.
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11. plan of study
Please outline, in English and in French, your plan of study and include in your description details about how the Fellowship
will help you to promote intercultural awareness, especially between French- and English-speaking Canadians, and to stimulate
exchanges between francophones and anglophones.
12. accomplishments
What were your most significant accomplishments of the last three (3) years? Please describe them, in English and in French,
and the work you undertook to accomplish them.
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13. other current and pending awards and/or fellowships
Please indicate other awards and/or fellowships to which you have applied and/or which you currently hold.
The Schmeelk Canada Foundation limits its awards so that recipients receive a total of C$35,000 in awards and/or fellowships per
annum. While the Foundation does not allow deferrals, it does allow partial 'top-up' award payments to a maximum of C$35,000.
name of award or fellowship
total amount (yearly)
applied
already
awarded
duration of Award
(Month/year to
Month/year)
_______________________________________________________
C$ _____________________
to
____________________
_______________________________________________________
C$ _____________________
to
____________________
_______________________________________________________
C$ _____________________
to
____________________
_______________________________________________________
C$ _____________________
to
____________________
14. knowledge of the fellowship program
How did you learn about the Richard J. Schmeelk Fellowship program? Please describe in English and in French.
15. appraisals
You must provide three (3) letters of appraisal, at least one of which is from an academic familiar with your work and at least
one of which is from a non-academic familiar with your accomplishments. These letters can be in either English or French. All
three letters should be provided by the sponsors in sealed envelopes with the sponsor’s signature across the seal to ensure
confidentiality, and included with this application. Please identify your three sponsors below:
#1
name
affiliation
relationship
#2
name
affiliation
relationship
#3
name
affiliation
relationship
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