Formulier auto immuun 2014
Candidature for the Scientific Award
Foundation AstraZeneca – Auto-immune
and Rheumatic diseases 2014
Fonds Wetenschappelijk Onderzoek – Vlaanderen
Research Foundation - Flanders
Egmontstraat 5 - 1000 BRUSSEL
Tel. 02 512 91 10 - Fax. 02 512 58 90
E-mail: [email protected]
To be filled in by the investigating
What is the purpose of this form?
With this form you can compete for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014. This
award will be granted to an individual postdoctoral fellow and rewards innovative basic, clinical or epidemiological research in the
field of auto-immune diseases, including inflammatory rheumatic diseases. The prize is intended to reward an established
investigator on the basis of his/her previous work, with a perspective of future development in the same field.
How to submit this form?
This form has to be submitted before June ,2 2014, at the e-mail address on top of this document.
How does the FWO handle the data in this form?
The FWO uses your information only for processing your candidature. The data will be handled confidentially and won’t be disclosed
to third parties.
As soon as the FWO has processed your application, you will receive a notification message.
Details of the candidate
1 Enter your personal details.
first name and surname
legal domicile address
date of birth
2 Enter the data of your account number.
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3 Give an overview of the achieved university diplomas (incl. PhD diploma).
4 Give an overview of your current and past functions with a biomedical context
university or institute
period (from / till)
Details of the research
Details of the research unit
5 Provide the name of your research unit and the name of the head of the research unit where you conduct
name of the research unit
name of the head of the research
Details of the proposed research
6 Describe the specific scientific domain of your research in three keywords.
7 Enter the English and Dutch title of the proposed project.
Use a maximum of 240 characters, including spaces.
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8 Give a description of the proposed work.
A memorandum of maximum 4 pages in English.
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9 Give an explanation of the expected results of the clinical & experimental research in the next 3 years .
Maximum 1 page in English.
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Details of scientific publications
10 Give an overview of your scientific publications and indicate those related to the prize.
For each publication, mention the following:
The title, completely without abbreviations
The journal, use only the internationally accepted abbreviations
Date of publication
The number of pages and for publications part of a book or magazine, the reference ‘from page x to page y’;
The names of the authors, according to the presentation order.
The impact factor of the journal
The number of citations for each paper
The FWO reserves the right to call for reprints.
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Other national and international awards
11 Did you already receive a national or international award for the same research described in the
12 List all national or international awards that you already have received, whether or not for this research.
Indicate for each prize the following data: the name, the period, the amount, the aim and the origin, i.e. the organization which
provided the award.
Title of the research
13 Enclose the following documents:
a detailed curriculum vitae
14 Fill in the following declaration.
I hereby confirm that all data and information is correctly filled in.
first name and surname
name of the award