Osler Library of the History of Medicine
McGill University
Mary Louise Nickerson Fellowship in Neuro History 
Dr. Dimitrije Pivnicki Award in Neuro-History and History of Psychiatry

Application for 2014 – 2015
Deadline: March 1, 2014

1. Short title of your project: _______________________________________________

________________________________________________________________________
 
2. Applicant’s name: _______________________________________________
			(last)				(first)

3. Present affiliation:	_____________________________________________________
(title)
_____________________________________________________ (department)
______________________________________________________
(institution)
______________________________________________________
(city, province/state, postal code/ZIP, country)

4. Mailing address:	______________________________________________________
(street)
______________________________________________________
(city, state or province, ZIP or postal code, country)

5. Telephone:  	________________________   _________________
		 	(work)				   (home/cell)			

6. E-mail address:	__________________________________________________

7. Education: 	Highest degree earned (please include a complete educational history in your CV, item 10):
___________		_________________________________ 
(degree)			(field)		

___________________________________________________
			(institution)

8. References: Provide contact information for two people who will be sending letters of recommendation:

	A. 	___________________________________________________________
		(name)
		____________________________________________________________
		(affiliation)			
		__________________	__________________
		(phone)				(email)

	B. 	____________________________________________________________
		(name)
		____________________________________________________________
		(affiliation)			
		__________________	__________________
		(phone)				(email)

Letters should be emailed to osler.library@mcgill.ca by the referee or mailed to: Nickerson Fellowship Committee, Osler Library of the History of Medicine, 3655 Promenade Sir William Osler, Montreal, H3G 1Y6, Quebec. 

9. Abstract of your project proposal; use only the space provided:

10. Curriculum Vitae: attach your current CV; make sure to include the following:
a. Educational history: include any programs in which you are currently enrolled, as well as post-doctoral experience. Include the institutions, the fields of study, degree received (if any), and the dates of enrollment. 
b. Research and professional experience: include all work experience that you consider relevant to this Fellowship.
c. Professional and academic honours: 
d. Personal Bibliography: include journal articles, book chapters, books or other publications, and theses and dissertations.

11. Project proposal: attach a description, in no more than one thousand words, of the project for which you are seeking this fellowship, including the ultimate goal (e.g. article, book, dissertation). Please indicate, as specifically as possible, the materials held in the Osler Library and other repositories at McGill and in Montreal which will be consulted.  Applicants must also indicate the length of time needed in Montreal.

12. Agreement and signature: read and sign.

If awarded the Mary Louis Nickerson Fellowship or the Dr. Pivnicki Award I agree to present a report suitable for publication in the Osler Library Newsletter and (if required) give a presentation of my work at the University.  I will also acknowledge the financial assistance of the Mary Louise Nickerson Fellowship programme or the Pivnicki Award in any subsequent publication or other work.

I certify that all information given in this application is true and complete to the best of my knowledge.

_______________________________
(applicant’s signature and date)

Please email this application to osler.library@mcgill.ca 

Deadline for all material is March 1st, 2014.