Dick Martin Scholarship Award – Application Form

Applicant's Personal Information

Applicant's Academic Information

Leadership and Civic Activities

Please provide a brief outline of your demonstrated leadership and civic activities, preferably in health and safety, but may also include other activities such as class president, volunteer work, participation in a service club, etc.


Please list two (2) references from a non-family member or personal friend.

First Reference

Second Reference

Essay and Letter Upload

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.

The Dick Martin Scholarship award is administered by the Canadian Centre for Occupational Health and Safety (CCOHS) with support from WorkSafeBC, the Canadian Union of Public Employees (CUPE) and the Canadian Labour Congress (CLC).

To learn more about the Dick Martin Scholarship Award, contact us.