Apply for a Research Scholarship

Research Scholarship Application Form
Applicant Type
Applicant's Full Name
Date of Birth
Contact Information
Address *
Address
City
State/Province
Zip/Postal
Country
Gender

Financial Position:

Do you have any other funding for your research? *

Secondary Education

University Education

(For Medical or Graduate Students) Medical or Graduate Education:

Post Graduate Training:

Graduated?

(For Active or Allied Health Professional) Current Position:

Description of Research:

Honors and Awards:

References

Applicant must submit the following:
1. two (2) letters of reference from educators, supervisors, a current Program Director or, in the case of active physicians or allied health professionals, colleagues in the same specialty.
2. current CV
3. abstract of submitted research
4. budget of estimated expenses
5. signed Consent Form for photos/videos (see last page of Application)
File Upload *
Maximum upload size: 268.44MB
Photo and Video Consent Form:
Permission is granted to ConnectMed International the right to use photos, videos and audio recordings of me or the research that is the subject of ConnectMed’s Research Scholarship Application for the purpose of marketing and publicity. Possible uses of recorded audio-visual or photographic media include but are not limited to; ConnectMed’s website (www.connectmed.org), ConnectMed’s social media accounts (such as Facebook, Instagram, Twitter and LinkedIn), ConnectMed’s quarterly newsletters and on ConnectMed’s YouTube channel.
X