145 Macquarie Street, Sydney NSW 2000               http://www.gesa.org.au            APPLICATION                   for   ...
Page 2                               SPECIFIC CONDITIONS:      DUKE CLINICAL RESEARCH FELLOWSHIP IN                  HEPAT...
Page 3                                             DATE RECEIVED:                                                   Applic...
Page 4  6     Citizenship/Medical/Professional Registration        (a) Are you an Australian citizen?                    E...
Page 5  8    Career Chronology From Beginning of Tertiary Studies       Positions held (include clinical positions and fur...
Page 6  9    Research Experience         a. Additional qualifications e.g. MD or PhD. (Where the applicant has completed a...
Page 7 10    Honours and AwardsGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
Page 8 11    Publications       The Applicant’s publications should be listed as:       i) Refereed journal articles (indi...
Page 9 12    Signatures       Applicant       Signature       Title and Name       Date       Title and Name       Date   ...
Page 10                               APPLICANT DETAILS   Name:   Institution:        GASTROENTEROLOGICAL SOCIETY OF AUSTR...
Page 11GESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
Page 12    FAILURE TO SUBMIT THIS REFERENCE BY THE DUE DATE OF 30 AUGUST 2008                  WILL RULE THE APPLICATION I...
Page 13                                                CHECKLIST                     Checklist of application requirements...
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SPECIFIC CONDITIONS:

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SPECIFIC CONDITIONS:

  1. 1. 145 Macquarie Street, Sydney NSW 2000 http://www.gesa.org.au APPLICATION for 2009 Duke University Clinical Research Fellowship In Hepatology Closing Date 31 August 2008 Postal & Courier Address GESA 145 Macquarie Street SYDNEY NSW 2000 Applications must be on this original application formLATE, FAXED OR INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED GESA—Application for Postdoctoral Research Fellowship
  2. 2. Page 2 SPECIFIC CONDITIONS: DUKE CLINICAL RESEARCH FELLOWSHIP IN HEPATOLOGY PURPOSEThe Fellowship is designed for Australian and New Zealand graduates seeking further training in researchmethodology and is to be undertaken at the Duke Clinical Research Institute at Duke University Medical Center,North Carolina. DEFINITIONAreas covered by the Fellowship will include hypothesis formulation, protocol development, statistical analysis,database organisation and manuscript preparation in the clinical investigation of liver disorders with a particularemphasis on viral hepatitis. CAREER STAGEThe Fellowship is intended for medical graduates with previous training in hepatology who are at or near theend of their clinical training. Previous experience in clinical research would be of benefit but is not essential. VALUERemuneration will range from US$30,000 - $40,000. Travelling expenses and accommodation are not provided. SUPERANNUATIONThe Society does not contribute to superannuation, loadings or continuation of service. Furthermore, timespent under this fellowship is unlikely to be counted as service contributing towards long-service leave or studyleave by the administering organisation. ADDITIONAL EARNINGSClinical patient care is negotiable with the institution should the applicant wish to accept the Fellowship for a twoyear period. TENUREThe Fellowship is for one year in the first instance with the possibility of an extension of a further year.The Fellowship will commence in January or February 2009. ELIGIBILITYAn applicant is required to:  Be a financial member of the Gastroenterological Society of Australia or the Gastroenterological Society of New Zealand. Financial is defined as “confirmed as a member of the society prior to taking up the award”;  Correctly complete the application form and lodge it with attachments and two (2) referee reports prior to the closing date.GESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  3. 3. Page 3 DATE RECEIVED: Application for Duke University Medical Center Clinical Research Fellowship in Hepatology Closing Date 31 August 2008 1 Title Gender (M/F) Surname Given Names Date of Birth Format: DD MM YYYY 2 I am a: (Please tick one category only) Medical graduate with MD/PhD (circle appropriate degree) Science graduate with PhD 3 Current Contact Address State Postcode Phone Facsimile EmailGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  4. 4. Page 4 6 Citizenship/Medical/Professional Registration (a) Are you an Australian citizen? Enter yes or no (ii) If you answered no to the above do you hold permanent Australian residency status? Evidence of residency status must be attached to application (b) Proof of Australian medical registration (if applicable) State of registration, registration number and expiry date: Please attach evidence of your current Australian registration. Applications received without this will not be further considered 7 Qualifications Please include the title of any theses produced. Applicants who have overseas qualifications should have their qualifications accredited by the Department of Education Science and Technology. If this is not able to be done by the time of application, the Head of Department and Head of Institution at the applicant’s institution should certify that the qualification in question is authentic and that accreditation will be undertaken by the Department of Education Science and Technology. Year’s Qualifications Institution Theses titleGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  5. 5. Page 5 8 Career Chronology From Beginning of Tertiary Studies Positions held (include clinical positions and further technical training), including current positions. Please list in chronological order. (a) Year Employment or Study Institution (b) (Medical graduate with further clinical training ONLY)—Indicate postgraduate clinical qualifications. First-part exam (or equivalent) passed Specialty training in progress OR Specialty training completedGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  6. 6. Page 6 9 Research Experience a. Additional qualifications e.g. MD or PhD. (Where the applicant has completed a research-oriented/based degree, they should indicate the duration, amount of research compared with coursework and whether it was full-time, part-time and/or concurrent with another degree.) b. Research experience e.g. electives, full or part-time research, apart from higher degreeGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  7. 7. Page 7 10 Honours and AwardsGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  8. 8. Page 8 11 Publications The Applicant’s publications should be listed as: i) Refereed journal articles (indicate clearly whether published or in press) ii) Other articles, reviews, book chapters, etc. iii) Published Abstracts iv) Case Reports v) PatentsGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  9. 9. Page 9 12 Signatures Applicant Signature Title and Name Date Title and Name Date Signature Title and Name DateGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  10. 10. Page 10 APPLICANT DETAILS Name: Institution: GASTROENTEROLOGICAL SOCIETY OF AUSTRALIASupporting Reference: Duke University Medical Center Clinical Research Fellowship in Hepatology Note: THIS REFERENCE IS TO BE FORWARDED WITH APPLICATION Closing Date: 31 August 2008FIRST NAMELAST NAMEMAILING ADDRESS POSTCODETITLEQUALIFICATIONSPRESENT APPOINTMENTS REFEREES ARE TO PROVIDE A SUPPORTING REFERENCE IN RELATION TO PREVIOUS RESEARCH WORK UNDERTAKEN BY THE APPLICANT IN WHICH YOU MAY HAVE BEEN INVOLVED: GESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  11. 11. Page 11GESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  12. 12. Page 12 FAILURE TO SUBMIT THIS REFERENCE BY THE DUE DATE OF 30 AUGUST 2008 WILL RULE THE APPLICATION INELIGIBLE. Signature of referee Date PLEASE ENSURE THAT THIS REFERENCE IS SUBMITTED WITH THE FULL APPLICATION.GESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009
  13. 13. Page 13 CHECKLIST Checklist of application requirements. This sheet must be completed. Applicant Department Institution Phone Number ( ) Yes No Certification of Medical/Professional registration in Australia Academic transcript (to be attached at the end of application) Two Supporting ReferencesGESA—Application for Duke University Medical Center Research Fellowship in Hepatology 2009

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