Formulier auto immuun 2014

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Formulier auto immuun 2014
Candidature for the Scientific Award
Foundation AstraZeneca – Auto-immune
and Rheumatic diseases 2014
FWO_WP_ASTRAZENECA_AIRD_20140227
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]
Website: http://www.fwo.be
To be filled in by the investigating
department
received date
number
file
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
private phone
department address
work phone
e-mail address
birthplace
date of birth
day
nationality
civil status
2 Enter the data of your account number.
IBAN
BIC
month
year
gender
m
f
Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014 - page 2 / 6
3 Give an overview of the achieved university diplomas (incl. PhD diploma).
diploma
university
date (dd-mm-yyyy)
4 Give an overview of your current and past functions with a biomedical context
function
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
your research.
name of the research unit
name of the head of the research
unit
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.
Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014 - page 3 / 6
8 Give a description of the proposed work.
A memorandum of maximum 4 pages in English.
Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014 - page 4 / 6
9 Give an explanation of the expected results of the clinical & experimental research in the next 3 years .
Maximum 1 page in English.
Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014 - page 5 / 6
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.
Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases 2014 - page 6 / 6
Other national and international awards
11 Did you already receive a national or international award for the same research described in the
memorandum.
yes
no
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
date
amount
aim
euro
euro
euro
euro
euro
Mandatory attachment
13 Enclose the following documents:
a detailed curriculum vitae
Signature
14 Fill in the following declaration.
I hereby confirm that all data and information is correctly filled in.
date
signature
first name and surname
day
month
year
name of the award
and origin

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