CCOHS: Dick Martin Scholarship: Application Form

Canadian Centre for Occupational Health and Safety

Centre canadien d'hygiène et de sécurité au travail

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Dick Martin

	About Dick Martin
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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.

If you would prefer to mail or fax in your entry please download and fill in the application form PDF pdf icon .

Applicant's Personal Information

I have read and meet/agree to all the award criteria*.
* 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*

*Preferably in health and safety, but may include other activities such as class president, volunteer work, participation in a service club, etc.
Please paste your essay in the text box below:*

		* Required fields

To learn more about Dick Martin, the scholarship opportunity, or to submit an application use the links in the sidebar or contact CCOHS at 1-800-263-8466.

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�CCOHS, 2006

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