NSERC Student Ambassadors (2019) Page 1 of 3

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Application Form NSERC Student Ambassadors

For more information, see NSERC Student Ambassadors description.

ELIGIBILITY Are you a Canadian citizen or permanent resident of Canada? Yes No

Are you currently enrolled in a Canadian university, polytechnic, college or Cégep in the natural sciences and engineering (NSE) or were you registered last term and plan to return next term to one of those institutions for studies in the NSE, or are you currently a postdoctoral fellow in the NSE at a Canadian university?

Yes No

Do you have a bank account with a bank located in Canada? Yes No

Are you at least 16 years old? Yes No

Is the proposed outreach activity a new, unique initiative undertaken by yourself (i.e., not affiliated with the activities or endeavours of other organizations)?

Yes No

If you answered “Yes” to all of the above questions, you are eligible to apply.

INFORMATION ABOUT THE APPLICANT Given name Family name NSERC PIN (if you already have one)

Telephone Email

Personal mailing address (street address, city, postal code)

Have you received a previous NSERC Student Ambassador award? Yes No

If yes, indicate the year of the most recent award__________________ and • attach a copy of the publicity related to that previous award; or• provide a URL ______________________________________

INFORMATION ABOUT YOUR INSTITUTION Name of institution Type of institution

University Polytechnic

College Cégep

Faculty/ Department Field within the NSE

INFORMATION ABOUT YOUR EVENT Title of proposed outreach activity

Subject of presentation Intended audience Expected number of participants

Location of event Date(s) proposed for event

Method of event promotion

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Proposed method(s) of sharing the results of the event publicly (e.g., social media)

Keywords describing the event (three words maximum)

Indicate the under-represented or disadvantaged group in the natural sciences and engineering you wish to target by checking the appropriate box(es).

Indigenous youth Girls Other (specify) ANTICIPATED EXPENSES Provide an itemized estimate of the expenses you anticipate paying with the $1,000 grant.

SUMMARY OF EVENT: Provide an overview of the proposed outreach activity including an explanation of how you will specifically target the under-represented or disadvantaged group(s) you have identified above and a justification of the need for the anticipated expenses.

Travel Accommodation Meals Material and supplies needed for the presentation/activity Event hosting Event promotion Total must equal $1,000

NSERC Student Ambassadors (2019) Page 3 of 3

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Terms and Conditions of Applying Form

Type of Award Applied for: NSERC Student Ambassadors

Family Name:

Given Name:

Before you, as an applicant, can submit your application to NSERC, you must read and agree to the following terms and conditions. It is your responsibility to retain a copy of the agreed terms and conditions for your records.

You are certifying that: • You have provided true, complete, accurate information in your funding application and related documents.• You will use the grant only for the purpose for which it was awarded.

• You will ensure that individuals who are named or identified in any document(s) or communications (i.e., pictures included in thepublic sharing of the results of your activity) related to your application or activities have agreed to be included and to disclose their personal information in the document(s) or communications.

• You are not currently ineligible to apply for and/or hold funds from NSERC, the Social Sciences and Humanities Research Council(SSHRC), the Canadian Institutes of Health Research (CIHR) or any other research or research funding organization worldwide for reasons of breach of policies on responsible conduct of research, such as ethics, integrity or financial management policies. If at any time you become ineligible for any of these reasons, you will advise your institutional officials and NSERC immediately, in writing.

• If you are or have been (at any time during the past 12 months) a federal public servant, you have complied with and will continueto respect the Values and Ethics Code for the Public Sector.

• You understand the Access to Information Act and Privacy Act and the Use and Disclosure of Personal Information Provided toNSERC as they pertain to your information.

• You will share the results of your activity publicly (e.g., online, social media) including an acknowledgement of NSERC support.• In the event of any change in your eligibility status, you will inform NSERC immediately, in writing.

• You are aware that if you fail to comply with any of these terms and conditions, you may be subject to the process and recourseoutlined in the Tri-Agency Framework: Responsible Conduct of Research.

SIGNATURES I have read and agree to all of the terms, conditions, responsibilities and obligations as set out above.

Signature of Applicant Date

If you are below the age of majority in your province/territory, a parent or guardian must co-sign this form.

Signature of Parent/Guardian Date

Not used in the adjudication

process

If you have any concerns about your ability to comply with the terms and conditions listed above, contact the staff responsible for the program immediately by sending an email to ambassadors@nserc-crsng.gc.ca. Do not agree to the terms and conditions and do not submit your application until you are certain that you can and will comply with all of the requirements.