Faculty of Agricultural and Food Sciences

University of Manitoba Graduate Fellowship Application 2014 2015

Department Deadline: Noon, February 10th, 2014

Please submit applications to the Department to which you are applying by the Department Deadline noted above.

University of Manitoba Graduate Fellowships (UMGF)

The Faculty of Graduate Studies offers new and continuing University of Manitoba Graduate Fellowships (UMGF) each year to meritorious students for full-time study and/or research (which includes works that are considered creative endeavours) leading to a graduate degree. Awards are made on the basis of academic excellence, and are open to students who will be registered as full-time graduate students (Masters or Ph.D.) at the University of Manitoba regardless of nationality or discipline during tenure of the award. Students must be recommended by their department to the Faculty of Graduate Studies. Only students with a minimum GPA of 3.90 in the last two completed years of study at a recognized university based on a Bachelor, Masters, Graduate Diploma or Doctoral degree will be recommended. Competition for the UMGF is strong each year and there are always many more students recommended than there are available awards. International GPAs are calculated using the equivalency criteria from the Faculty of Graduate Studies website http://umanitoba.ca/faculties/graduate_studies/facultyinfo/assess/index.php For tips on calculating United States and other Canadian universities GPAs, please go to the following Graduate Studies website: http://umanitoba.ca/faculties/graduate_studies/admin/568.html Students should contact their departments for more information on departmental review processes and deadlines. Offer of a UMGF does not guarantee admission into a graduate program at the University of Manitoba.

I. Value
Value for a 12-month period Ph.D. Masters $16,000.00 $12,000.00

II. Eligibility
Applicants must meet ALL eligibility requirements. Academic standing - Students with a minimum GPA of 3.90 in the last two full years of study (equivalent to 60 credit hours) at a recognized university based on a Bachelor, Masters, Graduate Diploma or a Doctoral degree. Citizenship All students regardless of citizenship are eligible to apply. Canadian citizens and permanent residents are encouraged to apply to CIHR, NSERC and SSHRC scholarships, if they are eligible for funding from these research councils. Students that do not apply for a national award may be considered ineligible for the UMGF Fields of study Students in all fields of graduate studies are eligible to apply.

Years of graduate study

The following students are eligible to apply for a UMGF in the Masters program Students in their final year of a bachelor degree program who will be entering a full-time Masters program as of May or September 2014 or January 2015 Students who have completed a bachelor degree program who will be entering a full-time Masters program as of May or September 2014 or January 2015 Students in a Pre-Masters program who will be entering a full-time Masters program as of May or September 2014 or January 2015 Students currently registered in the first year of a Masters program

The following students are eligible to apply for a UMGF in the Ph.D. program Students entering a full-time Ph.D. program as of May or September 2014 or January 2015 Students currently in the first, second or third year of a Ph.D. program Students transferring to a full-time Ph.D. program from a Masters program (note: students who transfer to a Ph.D. program from a Masters program without getting a degree - time spent in a Masters program will count as part of the Ph.D. program in determining eligibility)

Students are eligible to receive the UMGF for the first two years of their Masters program and the first four years of their Ph.D. program. Total maximum UMGF support for any individual graduate student is four years. In computing years of graduate studies, two years of a part-time study are equivalent to one-year of full-time study. For students who have not yet begun a graduate program at the University of Manitoba, applications will be considered, regardless of whether the student has completed a formal application for admission to the Faculty of Graduate Studies. However, such applicants must provide evidence that they satisfy the English Language Requirements for admission to the Faculty of Graduate Studies (see http://umanitoba.ca/faculties/graduate_studies/admissions/139.htm)

III. External Funding

UMGF awards are funded from University sources. With more students applying for and gaining external funding, more funds are available to students who are not eligible for external funding. Departments are requested to ensure that all eligible students apply for external funding. Students are strongly encouraged to take advantage of every funding opportunity to allow those students ineligible for external scholarships access to UMGF awards. Therefore, it is expected for students who are Canadian citizens or permanent residents to apply for external scholarship, if they are eligible, from the major research councils (NSERC, SSHRC and CIHR). Students that are eligible to apply for the MHRC are also expected to apply for the scholarship in order to be considered for the UMGF competition. Eligible students who do not apply for external scholarships may be considered ineligible for UMGF funding. Students offered a national, provincial or international funding for full-time study and/or research at the University of Manitoba will be required to accept the external funding and decline the UMGF. UMGF Renewals - Students who are awarded a UMGF are required to apply for external funding if they are eligible, to qualify for subsequent year(s) of funding. Students who are eligible to apply for external funding but do not do so will be considered ineligible for renewal of their award.

IV.

Funding Limits

The UMGF is not tenable with any other scholarship that has a greater monetary value than the UMGF award.

V.

Transfers

Students awarded a UMGF may transfer their award from one University of Manitoba (U of M) department to another, with the approval of the Dean of the Faculty of Graduate Studies. The student must request the transfer in writing to the Dean of Graduate Studies. The transfer request must be recommended and signed by the students advisor/supervisor, the Head of the former department and the Head of the proposed department. If a student transfers courses from one Masters program to another, their eligibility in the second program is limited to 24 months less the number of months spent in the first year of their Masters program. If no courses (ie. credit hours) are transferred to a second Masters program, then the student is eligible for the full 24 months of UMGF support at the Masters level. UMGF Masters recipients who transfer from a Masters to a Ph.D. in the middle of an academic year will continue to receive funding at the Masters level until the end of that academic year. To receive funding at the Ph.D. level, the student must re-apply in the next competition as a Ph.D. student.

VI.

Start Date and End Date

Start Date Normally the start date for the UMGF is September the beginning of the academic year. An early (May) start date may be approved upon receipt of a signed letter on letterhead from the students advisor supporting the request for payments to begin in May. Please note that if the first instalment is paid in May and the first admission date to the current program was in the month of September, the fellowship will terminate at the end of April in a subsequent year. Students may also defer the start of their UMGF to the January; normally such a deferral will occur if a student is beginning their graduate program at the University of Manitoba in January. Fellowships may be deferred to January only. Recipients must decline the UMGF and reapply in the next competition if they are unable to accept the fellowship upon a deferral to January (i.e., if the award cannot be taken up in January, after having been deferred from September, then it must be declined). Students admitted under the provisional status may not receive the award during the provisional period and may not accept the award if the provisional status is not cleared within a 4-month (one-term) period. End Date All awards are terminated as follows: Completion of Degree Students will have their UMGF award pro-rated to the end of the month in which they complete their degree requirements. The date of degree completion is the date on which all requirements for a degree have been met, including successful defense and submission of the final copies of the thesis to the Faculty of Graduate Studies. Students will be required to return any amounts issued to them for the time period after this date. Withdrawal from Program Students will have their UMGF award pro-rated to the date by which their withdrawal from their degree program is effective. Students will be required to return any amounts issued to them for the time period after their effective withdrawal date. Any fellowship payment received covering any period of ineligibility must be repaid in full.

VII.

Award Payment

Students must be admitted and registered as full-time graduate student without provision in the academic year that they are receiving a UMGF. UMGF payments are disbursed in biweekly instalments and will be directly deposited to their account. May payment is contingent upon continued eligibility and approval of a satisfactory renewal form which UMGF recipients will receive in December. Award payments are not credited towards tuition. Students are responsible for paying their own tuition.

VIII.

Selection and Announcement

The Faculty of Agricultural and Food Sciences Graduate Awards Committee will make the final selection of award recipients Selection Criteria Applicants for the UMGF are evaluated and selected according to the criteria in the following categories: Academic excellence - academic record Achievements. Achievements will be evaluated relative to the applicants stage in their program. Awards - scholarships and awards held

Research ability or potential - quality of contributions to research and development (including works considered creative endeavors) - relevance of work experience and academic training - ability to think critically - ability to apply skills and knowledge - judgment - originality - initiative and autonomy - enthusiasm for research - determination and ability to complete projects within an appropriate period of time Communication Skills - The ability or potential to communicate scientific concepts clearly and logically in written and oral formats. For example this could include: i. quality of the applications presentation ii. participating in preparing publications iii. awards for oral presentations or papers

Leadership - Professional and relevant extracurricular interactions and collaborations. For example, these could include: i. mentoring ii. teaching iii. supervisory experience iv. project management v. chairing committees vi. organizing conferences and meetings vii. holding of elected positions in relevant organizations

Selection Criteria Weightings Masters 60% 10% 10% 10% 10% Ph.D. 40% 30% 10% 10% 10%

Academic Excellence (GPA) Achievements Leadership References Department Heads Comments and Ranking

Notification of decision The Faculty of Graduate Studies notifies applicants of the results in writing. The Faculty of Graduate Studies will not provide results by telephone, by e-mail or in person. Students may also obtain the results from their respective departments. Successful applicants will receive a notice of award and must refer to the relevant UMGF Award Holders Guide, which contains instructions on how to obtain payment as well as the regulations pertaining to their award.

INSTRUCTIONS ON COMPLETING THE UMGF APPLICATION FORM

GENERAL PRESENTATION When you prepare your application and supporting materials, follow these guidelines: Print must be in black ink (typed or printed), and be of letter quality (minimum standard). Text must be single-spaced, with no more than six lines per inch. If you use a type size measured in points (pts), it must be no smaller than 12 pts. If you use a type size measured in characters per inch (cpi), it must be no more than 10 cpi. Condensed type is not acceptable. The on-line application form is automatically formatted to meet these standards and the type size cannot be changed.

Notes: Save your changes to the on-line application using Save as. You must print out a hard copy of the electronic application form after it is completed, sign it, and submit it along with required attachments/documentation to your department by the deadline. Attachments (free form) Use white paper Either use letter size paper (8 x 11 inches [21.5 x 28 cm]) and set margins at of an inch (1.9 cm) (minimum) all around. or use A4 paper (21 x 29.7 cm) and set left and right margins to 1.7 cm, and top and bottom margins to 2.7 cm (minimum). Enter your name at the top of every page. Print on one side of the paper only. Please follow the regulations pertaining to the number of pages allowed. Pages in excess of the number permitted will be removed.

What does my signature on the application mean?

You accept the terms and conditions of the award as set out in the UMGF regulations (attached to the application form) and the Award Holders Guide. You will acknowledge, wherever possible, UMGFs funding assistance You certify that the information provided in your application is complete, accurate and consistent with institutional policies to the best of your knowledge. The provision of false or inaccurate information may result in sanctions, including termination of funding and disentitlement from eligibility for future funding.

PART I FOR APPLICANT TITLE Mr/Ms/Mrs/Miss/Dr title is used when corresponding with the applicant LAST NAME & FIRST NAME Name should match all documents enclosed with the application and will appear when corresponding with the applicant. If the name on the application differs from transcripts and/or other documents enclosed with the application, the applicant is required to submit documentation (ie marriage certificate) to clarify the applicants identity. ADDRESSES Current address information will be used when corresponding with the applicant unless otherwise noted.

STUDENT NUMBER This number is provided to you by the University of Manitoba and will be your reference number in all correspondence with the Faculty of Graduate Studies. If you do not have a student number or if you do not know what your student number is, leave this section blank. ACADEMIC BACKGROUND Include only current and past programs. Do not include programs that you have not yet started. ENGLISH LANGUAGE COMPETENCE Complete this section if none of your completed degrees listed in the previous section are from a Canadian university or from a university in a country on the English Language Exemption list. Before completing the section, consult the Faculty of Graduate Studies information on English language requirements: http://umanitoba.ca/faculties/graduate_studies/admissions/139.htm Remember to attach the required documentation to your application. OTHER RELEVANT WORK EXPERIENCE In the area labelled Position held under nature of work, specify whether the employment was full- or part-time. Also, indicate if you gained the experience in the course of a program of study. AWARDS & SCHOLARSHIPS RECEIVED Starting with your most recent awards, give the name of the award, the value, the type (institutional, provincial, national, or international), the location of tenure, and the period held. Only list the support awarded on the basis of academic and research excellence and/or in recognition of your leadership or communication skills. PUBLICATIONS (one free form page may be appended) List your contributions to research and development and works considered creative endeavours. Begin with your most recent, and list each entry on a new line. Do not include any articles that are currently in preparation. Use the following headings and order in your listing: a. b. c. d. e. f. g. Articles published or accepted in refereed journals; Articles submitted to refereed journals; Other refereed contributions (e.g., communications, papers in refereed conference proceedings, posters etc.); Technology transfer; Contributions resulting from your participating in industry relevant R&D activities; and Patents and copyrights (e.g., software, but excluding publications). Un-refereed posters or papers presented in conferences or meetings

For publications submitted or in press, indicate the date of acceptance/submission and the number of pages submitted. In all cases, indicate whether the publication resulted from work done in the process of completing your undergraduate, masters or doctoral degree, or from other relevant work experience. THESES COMPLETED OR IN PROGRESS Provide information for all degrees involving completion of a thesis. For completed degrees, indicate the date by which you completed all degree requirements (date of completion of all courses, thesis defence, corrections, and deposition of thesis, not the convocation date). LEADERSHIP ACTIVITIES List activities that best demonstrate leadership and community involvement. Begin with the most recent and indicate the organization, time involved and give a brief description of your role. You can include all activities since starting university, but since you are limited to one page, you may need to be selective.

Part II
REFEREES Two letters of support must be included with the UMGF application form What you should do Provide a photocopy of your completed application to each of your two referees. Provide each referee with the instructions and the original of Part II or refer them to the on-line form. Allow sufficient time to enable your referee to complete, print and return the form. The referee must return the form and the letter of reference to you in a signed and sealed envelope or send it directly to the department through which you are applying.

Part III
DEPARTMENTAL COMMENTS The department head, the heads representative or a committee of the department through which you are applying must complete this part of the form.

How to complete Part II of the UMGF application FOR REFEREES

Who should complete this form? Complete this form if you have agreed to evaluate an applicant for a UMGF award. Use this form in conjunction with the applicants completed copy of the UMGF application form Once you have completed the rating form and have attached a letter of support, the Faculty of Graduate Studies Awards Committee will use it to review and assess the application for an award. Complete and submit the signed form and the letter of support prior to the deadline. The Awards Committee will not consider the application without it. Either return the form and the letter of reference to the applicant in a signed and sealed envelope or send it directly to the department to which the applicant is applying. GENERAL PRESENTATION When you prepare your report on the applicant, follow these guidelines: The form and letter of support must be typed or printed Print must be in black ink, and be of letter quality (minimum standard) If you use a type size measured in points (pts), it must be no smaller than 12 pts. If you use a type size measured in characters per inch (cpi), it must be no more than 10 cpi Condensed type is not acceptable. A one-page letter of support must be appended (this letter should be consistent with the ratings provided in the grid)

How to complete this form Rate the applicant on each of the evaluation criteria in the grid and justify your evaluation in the supporting letter. Rather than providing general comments, assess the applicants strengths and limitations for each criterion. Include specific examples of the applicants accomplishments and contributions to support your assessment. Note If you provide exceptionally high or low ratings that are inconsistent with the application as a whole, they may diminish the reports credibility. Please note that this report will be accessible to the applicant with your particulars blocked out.

How to complete Part III of the UMGF application FOR DEPARTMENT HEAD OR DESIGNATE
Who should complete this form? Complete this form if you are evaluating an applicant for a UMGF award and you are the head of the department or a representative. What do you need to complete this form? Before you start completing this form to evaluate the applicant, make sure you have: The applicants completed copy of the UMGF application form Completed originals of Part II ratings form grid to be completed by two referees and a letter of support from each of the two referees. The applicants official academic transcripts (certified true copies and/or student histories are acceptable) web print out and Student Aurora print outs are not acceptable

Complete this evaluation for all UMGF applicants through your department regardless of their status. This information contributes to a fair assessment and comparison of all applicants whether they are currently attending the University of Manitoba or not. If you are unable to provide a useful evaluation due to the lack of contact with the applicant, please indicate this on the form. GENERAL PRESENTATION When you prepare your departmental evaluation, follow these guidelines: The form must be typed or printed Print must be in black ink, and be of letter quality (minimum standard) Text must be single-spaced, with no more than six lines per inch. If you use a type size measured in points (pts), it must be no smaller than 12 pts. If you use a type size measured in characters per inch (cpi), it must no more than 10 cpi. Condensed type is not acceptable.

Please pay careful attention to the program that the applicant is entering during tenure of the award. This will affect the criteria used in assessing the applicant and the value of the award. Departmental Comments on the Applicant Discuss the qualities or factors that led to the departmental ranking of the applicant. Comment on the applicants strengths and limitations in comparison to the peer group using all of the following criteria: Academic excellence (based on performance in the current program and in the last 60 credit hours before entry into the current program) Research ability or potential Communication skills Interpersonal and leadership skills

Explain any discrepancies between the comments and ratings in Part II, completed by the referees, and Part III, the departmental comments. If there were any unusual circumstances that may have affected the applicants performance, please explain them. Please do not recommend applicants - whose GPA in the last 60 credit hours of degree program(s) from a recognized university is below 3.90 - who will exceed 24 months of a Masters program as of September in the competition year (for a UMGF Masters) - who will exceed 48 months of a Ph.D. program as of September in the competition year (for a UMGF Ph.D.)

Application for
UNIVERSITY OF MANITOBA GRADUATE FELLOWSHIP PART I
Title Last Name of Applicant First Name Initial of all given names

ADDRESSES
Current address (street name & number/City/Province/Postal Code) Permanent mailing address (if different than current address) (street name & number/City/Province/Postal Code)

If current address is temporary, indicate leaving date

Telephone number at permanent mailing address

Telephone number

Facsimile number

E-mail address

U of M student number

Present Department

Present Institution

I propose to study for

CITIZENSHIP

Ph.D. Degree

Masters degree
Permanent resident of Canada

during 2014-2015 academic year

Canadian Citizen

Visa student

SIGNATURE
I hereby agree that any award made to me as a result of this application will be subject to the general conditions governing the UMGF. These conditions are outlined in the regulations attached to this application form, as well as the regulations outlined in the Award Holders Guide. I hereby certify that I have read and understood the instructions and information sheet attached to this application form and that all statements made in connection with this application are true and complete. I authorize the university to verify any information, transcripts, or reference letters provided as part of this application. I understand that my application will be rejected if I have not disclosed my complete academic record or have submitted false information in support of my application to the Faculty of Graduate Studies. In such an event I understand that future applications from me will not be considered.

____________________________________________ Date

_______________________________________________ Signature of Applicant

This personal information is being collected under the authority of The University of Manitoba Act and will be used for the purpose of assessing your application for the UMGF competition. It may be shared with other educational institutions. Information regarding graduation and awards may be made public. Upon your graduation, name, address and degree information you have provided will be given to and maintained by the Alumni Records department in order to assist in the Universitys advancement and development efforts. This information is protected by the Protection of Privacy provisions of Manitobas Freedom of Information and Protection of Privacy Act. If you have any questions about the collection, contact the FIPPA Coordinators Office (204) 474-8339, c/o Archives and Special Collections, 331 Dafoe Library, University of Manitoba, Winnipeg, MB, R3T 2N2.

Last Name of Applicant

First Name

ACADEMIC BACKGROUND (current and past degree programs including in programs in progress)
Degree Name of discipline Department, Institution and country Month and year started Month and year awarded/expected Status (PT/FT)

Bachelors

Masters

Doctorate

Other

ENGLISH LANGUAGE COMPETENCE Complete this section if you are not currently a University of Manitoba student and none of your
completed degree programs is from a Canadian university or a country on the English Language Exemption List. (see http://umanitoba.ca/faculties/graduate_studies/admissions/english_exemption_list.htm) Either or I am enclosing a certified copy of my high school diploma from a Canadian high school or from a high school in a country on the English Language Exemption List I am attaching a certificate showing that within the last two years I have exceeded the minimum requirements on one of the English Language Proficiency Tests listed at http://umanitoba.ca/faculties/graduate_studies/admissions/139.htm

OTHER RELEVANT WORK EXPERIENCE

Position held and nature of work (begin with current) Organization and department Supervisor Period (mm/yyyy mm/yyyy)

Last Name of Applicant

First Name

(indicate award type: international, national, provincial, or institutional) Award Name and Value Type University Period (mm/yyyy mm/yyyy)

AWARDS & SCHOLARSHIPS RECEIVED

Last Name of Applicant

First Name

PUBLICATIONS (List papers published in refereed journals, book and proceedings, papers and posters presented at conferences and other
published evidence of productivity beginning with the most recent. One additional page may be appended if needed).

Last Name of Applicant

First Name

THESES COMPLETED OR IN PROGRESS

1. Degree Supervisor Date degree requirements completed

Title of thesis

2. Degree

Supervisor

Date degree requirements completed

Title of thesis

LEADERSHIP ACTIVITIES Provide information on activities that demonstrate leadership or community involvement. Include both academic and
non-academic leadership activities undertaken since the date of first entrance to a university Organization Dates and frequency Description of involvement

Last Name of Applicant

First Name

REFEREES Provide information on two referees who will complete Part II of the application and will submit a letter of support.
Last Name First Name

Position

Department/Division

Institution

Telephone No.

Facsimile No.

E-mail address

Last Name

First Name

Position

Department/Division

Institution

Telephone No.

Facsimile No.

E-mail address

UNIVERSITY TRANSCRIPTS List all university transcripts appended to this application. You must include all undergraduate and graduate

transcripts. Only official transcripts, student histories from the Registrars Office and certified true copies are acceptable. Web printouts and Student Aurora printouts are not acceptable. These documents must be in originally sealed envelopes at the time of receipt at the departmental level.

PART II TO BE COMPLETED BY REFEREE

This report is CONFIDENTIAL and must be completed by the students proposed advisor or a faculty member from any academic institution with special knowledge of the student. Last Name of Applicant First Name

THIS REPORT CONSISTS OF THREE PARTS AND ALL PARTS MUST BE COMPLETED: The information provided on this form is most important to the Awards Committee in evaluating the suitability of the candidate for receiving the UMGF. You are therefore asked to give detailed information (both pros and cons) about the candidate. (2.1) How long have you known this student and in what capacity? (professor, supervisor, committee member etc.) (2.2) Check the boxes that most nearly represent your opinion of the candidate in comparison with a representative group of individuals you have known who have had approximately the same training and experience. (2.3) The letter of support should be typed or printed in black, as the material must be duplicated for the peer review process. 2.1 I have known this applicant for ____________ (#) years in the capacity as his/her _________________________ (professor, advisor, committee etc.) On the basis of my experience with _______________ (#) students at a similar level over _______________ years, I would give this student the following rating: 2.2 RATING FORM (Note: Ratings should be consistent with information contained within the body of the application form including the marks on the transcripts) EXCEPTIONAL Upper 2% Academic preparation Demonstrated scholarly ability Demonstrated research ability Communication skills (written) Communication skills (oral) Industriousness/ motivation Creativity Upper 10% EXCELLENT Upper 15% Upper 20% VERY GOOD Upper 33% GOOD Upper 50% ACCEPTABLE Lower 50% UNABLE TO JUDGE

Originality

Judgement

2.3 PLEASE ELABORATE ON THE ABOVE RATINGS BY ATTACHING AN ADDITIONAL LETTER OF SUPPORT (REQUIRED)
Name of Respondent (Print) Signature

Position

Institution

PART III CONFIDENTIAL NOTE: Application forms submitted without transcripts attached and without departmental cover sheets will be returned to the de partment and m arked i ncomplete. T HE A WARDS COMMITTEE G IVES CONSIDERABLE WEIGHTING T O THIS SECTION. PLEASE ENSURE THAT THIS SECTION IS COMPLETED WITH CARE AND THAT ANY DISCREPANCIES BETWEEN THE ACADEMIC RECORD AND THE REST OF THE APPLICATION IS ADDRESSED HERE. TO BE COMPLETED BY THE HEAD OF THE DEPARTMENT OR REPRESENTATIVE
Last Name of Applicant First Name

Among the ____________ students from this department who are recommended, this student ranks _____________ This student will be in the _________________ year of the __________________ (Masters/Ph.D.) program as of September 1, 2014 and is expected to complete all degree requirements by _______________________. For students applying for the first year of Ph.D. study please indicate one of the following:

The student will complete the Masters program prior to entering the Ph.D. ; or

The student will transfer to the Ph.D. program without completion of a Masters. Provide a r ationale f or t he r anking as signed t o t he appl icant. Provide ev idence of t he q uality and merit of t he s tudent and how t he s tudent r ates i n comparison t o hi s/her peer s. T he A wards C ommittee i s par ticularly i nterested i n information t hat is not otherwise available to t hem, f or ex ample: assessment of the quality of the applicants publications or presented papers, encounters by department personnel with the applicant that has allowed assessment of their ability, previous experience with students from the applicants source institution, or observations on the judgement or reliability of the referees.

The candidate is RECOMMENDED NOT RECOMMENDED Please do not recommend candidates whose GPA for the last 60 credit hours of study is below 3.75 NOT RECOMMENDED applicants will not be considered by the Awards Committee Name of Respondent (Print) Department

Signature

Date