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>Application Form

In memory of a tireless health and safety advocate Dick Martin "Canadian pioneer for workplace health and safety"

Dick Martin
1944-2001

Use the electronic application form below to submit your entry for the Dick Martin Scholarship.

Applicant's Personal Information

I have read and meet/agree to all the award criteria.
NOTE: You must be enrolled, either full-time or part-time, in an Occupational Health and Safety related course or program at an accredited college or university in Canada.

First Name*

Last Name*

Address*

City/Town*

Province*

Postal Code*

E-mail*

Telephone*

Academic Information

College/University*

Address*

City/Town*

Province*

Country*

Program Enrolled In*

(Certificate/Diploma/Degree)

Program Contact*

Academic Achievements

Brief outline of demonstrated leadership and civic activities

NOTE: Preferably in health and safety, but may include other activities such as class president, volunteer work, participation in a service club, etc.

Please list two references form a non-family member or personal friend.

First Reference*

Title (if applicable)

Relationship to applicant*

Phone number*

E-Mail Address*

Second Reference*

Title (if applicable)

Relationship to applicant*

Phone number*

E-Mail Address*

Upload

Cover Letter*

Essay*

Note: All files must be either a PDF or Word Document and no larger than 5 Megabytes

* Required fields

Provision of the information requested on this form is voluntary. We will use your personal information for the following purpose(s):

The information is being collected to provide information for the purpose of awarding scholarships which you have elected to submit an application for.
The information collected on this form/Web page is described in Personal Information Databank Automated Document, Records, and Information Management Systems Bank Number: PSU 904.
Retention and Disposal Standards: For information about the length of time that specific types of common administrative records are maintained by a federal government institution, including the final disposition of those records, please contact the institution's Access to Information and Privacy Coordinator.

Your personal information is protected under the federal Privacy Act, which states that you have the right to access your personal information and request changes to incorrect information. If you wish to avail yourself of this right or require clarification about this Statement, contact our Privacy Coordinator by email at privacy@ccohs.ca or by calling 905-572-2981 ext 4401 or writing to 135 Hunter St E, Hamilton, ON L8N 1M5. For more information on privacy issues and the Privacy Act in general, consult the Office of the Privacy Commissioner Web site or call 1-800-282-1376.

The transmission of this optional information is not secure and so sensitive personal information, for example, your Social Insurance Number, should not be included in your message.

If after reading this statement, you prefer to submit your comments off the Internet, contact us at scholarships@ccohs.ca

To learn more about Dick Martin, the scholarship opportunity, or to submit an application use the links in the sidebar or contact CCOHS at 1-800-668-4284.

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CCOHS

Dick Martin Scholarship

Accessibility

Transparency

Proactive Disclosure

>Application Form

Applicant's Personal Information

Academic Information

Brief outline of demonstrated leadership and civic activities

Upload