20200323170513060596.docx&filename=ICGEB联合研究项目申请表（2020）.docx

ICGEB CRP Application Form 2020 For ICGEB internal use only Proposal Number: Date of receipt: (assigned by ICGEB) FORM A 2020 Application Form Project title Principal Investigator* Institute (Name & Address): Telephone: Fax: E-mail: Signature Date of Submission *Name of the scientist responsible for the coordination of research and for the submission of the application on Forms A and B. The Principal Investigator must be an employee of the Institution receiving the grant. Endorsed by ICGEB Liaison Officer** of ………………………………………. (Country**) Full Name Signature Date of Submission **Refer to the Annex A for the list of eligible countries and to https://www.icgeb.org/governance/members-states/ for the full contact details ICGEB CRP Application Form 2020 FORM A.1 Confirmation by the Institute We hereby confirm that (Principal Investigator’s full name) is working in this Institute as (position) since (dd/mm/yy) The Principal Investigator is authorised to request the funds that will be necessary to carry out the proposed research. Should this application be selected for funding, the administrative official authorised to sign the contract on behalf of the Principal Investigator’s Institute will be: Legal Representative* (Full name) Name & Address of Institute: Telephone: Fax: E-mail: Signature Date of Submission Official stamp of the Institution (if any) * An official of the Institution fully empowered to enter into contracting arrangements on behalf of the Institution 1 ICGEB CRP Application Form 2020 FORM B 1 Curriculum Vitae of Principal Investigator (attach additional pages if necessary)  Part I Surname First Name Gender Birth date (dd/mm/yy) Male Female Nationality Position title Name of Institute Full address of Institute Tel: Fax: E-mail: Have you previously received a grant (CRP) from the ICGEB? YES NO If yes, please indicate the Ref. No.: CRP/_______________________ Have you previously received an ICGEB Fellowship? YES NO If yes, please indicate whether it was a short-term fellowship pre-doctoral fellowship post-doctoral fellowship Is this an application for an Early Career Return Grant*? YES NO *The following conditions must be met: (i) the applicant must not be over 40 years old at the time of application (ii) the applicant must have an outstanding track record, (iii) have spent at least 2 years abroad, and (iv) must have returned to an ICGEB Member State (except Italy) to establish their own independent laboratory no more than 2 years before the application Is this a resubmission of a previous application submitted to ICGEB? NO (please note that a proposal can only be re-submitted once) YES If yes, attach a pdf file explaining the changes to the original proposal Does your proposal require Ethical Approval? YES If yes, please attach relevant information 2 NO ICGEB CRP Application Form 2020  Part II - Education (begin with initial professional education) Institute & location Degree Year Field of study  Part III – Current & previous employment  Part IV - Current & previous grants awarded (last 5 years)  Part V - Publications (Attach publication list, including peer-reviewed research papers, books and patents. Highlight those that are directly relevant to this application) 3 ICGEB CRP Application Form 2020 2 Project 2.1 Title 2.2 Summary (Provide a layman’s summary of your research proposal, to be understood by a non-academic audience. Explain the context of the research, its aims and objectives and including the potential future applications/benefits in no more than 150 words. In case of award this section will be published on the ICGEB website.) 2.3 Abstract (Provide a scientific summary of your research proposal) 4 ICGEB CRP Application Form 2020 Please do not exceed this space 5 ICGEB CRP Application Form 2020 3 Introduction Provide a concise background to the project, highlighting the question(s)/hypotheses to be addressed (Maximum 1 page) 6 ICGEB CRP Application Form 2020 4 Research Project 4.1 Define the specific research activities to be pursued during the project period, providing a comprehensive description of the techniques to be used and the advantages of the suggested methodological approach. Please include any selected relevant references. (Maximum 5 pages, including references) 7 ICGEB CRP Application Form 2020 4.2 Time schedule (Specify work elements within the time frame of the project) 4.3 Potential for training of young scientists & collaborations (Specify if training of young scientists and any travels are foreseen. Please indicate the potential for collaborations with ICGEB groups and/or other laboratories and attach copies of any confirmation letters from collaborators. Before completing this section read the notes provided in the application guidelines.) 8 ICGEB CRP Application Form 2020 4.4 Facilities available in the Investigating Team’s laboratory (Provide a detailed list of the infrastructure and equipment that are available and necessary for the proposed research) 4.5 Feasibility (Indicate the expertise of the PI and the assembled team that is relevant for performing the proposed research) 9 ICGEB CRP Application Form 2020 5 Financial Contribution indicated in Euro) requested from ICGEB (all figures to be Please read carefully the Budget Guidelines and provide annual breakdowns, in Euro, of the requested funds, together with a brief description of the foreseen expenditures. 1st year 2nd year 3rd year Total per budget category Equipment1 Consumables2 Training3 Travel4 Literature5 Sub total TOTAL CONTRIBUTION REQUESTED FROM ICGEB (The maximum annual contribution requested cannot exceed Euro 25,000) Euro 1Equipment This budget category must not exceed 30% of the total grant requested/awarded – please refer to the Budget Guidelines Please provide a justification for each item to be funded with the ICGEB grant 1) 2) 3) 4) 5) 2Consumables 3Training & Training – please refer to the Budget Guidelines – please refer to the Budget Guidelines 10 ICGEB CRP Application Form 2020 4Travel This budget category must not exceed 10% of the total grant requested/awarded – please refer to the Budget Guidelines 1) 2) 3) 4) 5) 5Literature This budget category must not exceed 5% of the total grant requested/awarded – please refer to the Budget Guidelines 11 ICGEB CRP Application Form 2020 6 Proposed Referees Provide the name and full coordinates of a maximum of 3 referees who would be willing to review your proposal. Reviewers should not be nominated from research organizations connected to the proposal or where possible conflict of interest may arise. Please note that the ICGEB will have the sole responsibility in deciding whether or not a proposal will be submitted for evaluation to the referee(s) listed below. Referee No. 1 Surname First Name Institute address Tel: Fax: E-mail: Referee No. 2 Surname First Name Institute address Tel: Fax: E-mail: Referee No. 3 Surname First Name Institute address Tel: Fax: E-mail: 12 ICGEB CRP Application Form 2020 7 Conflict of interest 7.a Please list any possible conflicts of interest 7.b Provide the name and full coordinates of potential referees that you would prefer we do not contact, due to possible conflicts of interest (no more than 3) Referee No. 1 Surname First Name Institute address E-mail: Referee No. 2 Surname First Name Institute address E-mail: Referee No. 3 Surname First Name Institute address E-mail: 13 ICGEB CRP Application Form 2020 8 Feedback (Please indicate, selecting only one choice, how you found out about the Collaborative Research Programme (CRP) – ICGEB Research Grant Programme) ICGEB Website Social networks ICGEB Liaison Officer Your University/Institute A colleague Other (please specify) 9 Disclaimer By completing this form, you will be only asked to enter the data, which are required in each specific case. ICGEB will handle the data confidentially, processing them for the purpose for which they were requested. Your data are used exclusively for statistical purposes and are not passed on to third parties, neither in full nor in extracts. There is no verification with other data records. Your email will automatically be entered into our database for communication on ICGEB funding and training programmes. Should you not wish your email to be used for such scope, please tick the box below. Should you decide to unsubscribe at a later stage, personal data will be irrevocably deleted after six weeks at the latest. Do not enter my email in the ICGEB mailing list 14 ICGEB CRP Application Form 2020 ANNEX A - ICGEB Member States eligible to apply for funding under the CRP – ICGEB Research Grant Programme For name of Liaison Officers and full contact details see: https://www.icgeb.org/governance/members-states/ AFGHANISTAN MAURITIUS ALGERIA MEXICO ARGENTINA MONTENEGRO BANGLADESH MOROCCO BHUTAN NAMIBIA BOSNIA AND HERZEGOVINA NIGERIA BRAZIL NORTH MACEDONIA BULGARIA PAKISTAN BURKINA FASO PANAMA BURUNDI PERU CAMEROON QATAR CHILE REPUBLIC OF MOLDOVA CHINA ROMANIA COLOMBIA RUSSIAN FEDERATION COSTA RICA SAUDI ARABIA CÔTE D’IVOIRE SENEGAL CROATIA SERBIA CUBA SLOVAKIA ECUADOR SLOVENIA EGYPT SOUTH AFRICA ERITREA SRI LANKA ETHIOPIA SUDAN HUNGARY SYRIAN ARAB REPUBLIC INDIA IRAN (ISLAMIC REPUBLIC OF) TRINIDAD AND TOBAGO IRAQ TURKEY JORDAN UNITED ARAB EMIRATES KENYA UNITED REPUBLIC OF TANZANIA KUWAIT KYRGYZSTAN URUGUAY VENEZUELA (BOLIVARIAN REPUBLIC OF) LIBERIA VIET NAM LIBYA ZIMBABWE TUNISIA MALAYSIA 15 ICGEB CRP Application Form 2020 16 ICGEB CRP Application Form 2020 CRP - ICGEB Research Grant Application Form 2020 Check List for Principal Investigator Have you English? completed all the sections of this application form in Have you signed Form A? Has the Legal Representative of your Institute signed Form A1? Have you completed section 5 (Financial contribution requested from ICGEB) according to the Budget Guidelines? Is the budget expressed in Euro? Submit your proposal by e-mail (as a pdf attachment) BOTH to: 1) the Liaison Officer of your country (refer to Annex A for the list of eligible countries and for full contact details) 2) the CRP-ICGEB Research Grants Unit (crp@icgeb.org) Please note that Principal Investigators are responsible for the correct submission of their proposal to the Liaison Officer. ICGEB is not responsible for failed submissions/undelivered messages. For ICGEB Liaison Officers Please note that incomplete proposals or proposals not submitted on the official 2020 application form will not be processed 17