Application and Terms and conditions of applying form

STEAM (2021) – Page 1 of 4

Part 1: PERSONAL INFORMATION (NOT SEEN BY REVIEWERS)Family name Given name Initial(s) of all given names

Mailing address

Telephone number Email address

CITIZENSHIP

Canadian citizen

Permanent resident of Canada

Date of landing ______________as stated on official immigration document

AGE

Will you be between the ages of 16 and 18 at the deadline date?

Yes No

INDIGENOUS SELF-IDENTIFICATION

Two awards are reserved for eligible Indigenous applicants and are funded by Indspire.

I self-identify as Indigenous (First Nations (North American Indian), Métis, or Inuit), and consent to this information, my personal information and my application being shared with Indspire in order to be potentially considered for one of these awards.

I agree with this statement.This statement does not apply to me / I do not agree with the above statement.

LANGUAGE OF CORRESPONDENCE

English French

SIGNATURES

Signature

Name of parent or guardian (if applicable)

Signature of parent or guardian (if applicable)

Date _____________

Date _____________

Date _____________

ACADEMIC BACKGROUND (Current institution)

Institution ___________________________ Start date ____________ End date _____________

PROPOSED LOCATION

Institution ___________________________ Department ___________________________

Program of study______________________

IMPORTANT: Read the Instructions for completing an application for details.

STEAM (2021) – Page 2 of 4 The information collected on this form will be stored Version française disponiblein the Personal Information Bank for the appropriate program.

PROTECTED B WHEN COMPLETED

Part 2: APPLICATION INFORMATION (SEEN BY REVIEWERS)Family name Given name

ACHIEVEMENT(S)

AMBASSADOR POTENTIAL

PROBLEM SOLVING WITH INNOVATIVE IDEAS

Not used inthe

adjudicationprocess

Terms and Conditions of Applying Form

Type of award applied for: INGENIUM-NSERC STEAM Horizon Awards

Family name:

Given name:

Before you can submit your application to the Natural Sciences and Engineering Research Council (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 andrelated documents, and you have represented yourself, your research and youraccomplishments in a manner consistent with the norms of the relevant field.

• you have ensured that individuals who are named in any document(s) related to yourapplication have agreed to be included and to disclose their personal information in thedocument(s).

• you are not currently ineligible to apply for and/or hold funds from NSERC, the SocialSciences and Humanities Research Council (SSHRC), the Canadian Institutes of HealthResearch (CIHR) or any other research or research funding organization worldwide forreasons 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 anyof these reasons, you will advise your institutional officials and NSERC immediately, inwriting.

• if you are or have been (at any time during the past 12 months) a federal publicservant, you have complied with and will continue to respect the Values and EthicsCode for the Public Sector.

• you understand the Access to Information Act and Privacy Act and the Use andDisclosure of Personal Information Provided to NSERC as they pertain to yourinformation.

• you consent to the sharing among the award sponsors (including but not limited to theIngenium foundation, Indspire and NSERC) and with any academic institution to whichyou are, or may become, affiliated of any and all information, including personalinformation, in any way related to the application and to the award.

• in the event of any change in your eligibility status, you will inform NSERC and yourinstitutional officials immediately, in writing, and hereby authorize the academicinstitution where you are employed or affiliated to provide to NSERC your personalinformation for the purpose of verifying your eligibility.

• you have read, understood, and you agree to comply with the Tri-AgencyFramework: Responsible Conduct of Research both in the submission of your applicationand in carrying out the research funded by NSERC.

By submitting your application, you are also confirming that, during tenure of thegrant/award, you will comply with the terms and conditions of the grant/award.

Consent to disclosure of personal information: You understand that maintaining publictrust in the integrity of researchers is fundamental to building a knowledge-based society. By

STEAM (2021) – Page 3 of 4

STEAM (2021) – Page 4 of 4 Version française disponible

Tri-Agency Framework: Responsible Conduct of Research. In

________________________

_________________________

submitting any application, or by accepting funding from CIHR, NSERC and/or SSHRC, you affirm that you have read, and you agree to respect all policies of the agencies that are relevant to your research, including thecases of a serious breach of agency policy, the agency may publicly disclose any informationrelevant to the breach that is in the public interest, including your name, the nature of the breach, the institution where you were employed at the time of the breach, the institution where you are currently employed and the recourse imposed against you. You accept this as a condition of applying for, or receiving, agency funding, and you consent to such disclosure. If you do not agree to the disclosure of your personal information, you cannot participate in this application. For further information, see the Consent to Disclosure of Personal Information Policy - Frequently Asked Questions.

CONFIRMATION OF AGREEMENT TO THE TERMS AND CONDITIONS OF APPLYING

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 schol@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.

SIGNATURESI confirm the truth of all statements made by me in this application, and agree to all of the terms, conditions, responsibilities and obligations as set out above.

_______________________________________ Signature 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