APPLICATION FOR FELLOWSHIPS

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Rachele Fede
6 anni fa
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1 Da inviare tramite posta o corriere e posta elettronica a: FONDAZIONE ITALIANA SCLEROSI MULTIPLA Vico chiuso Paggi, Genova fism@aism.it APPLICATION FOR FELLOWSHIPS Title of training or research programme (in English) Titolo del progetto di borsa di studio (in italiano) Research area Neurobiology Genetics Neuroimmunology (experimental and clinical) Neuroimaging Biological Markers New experimental models Therapy (pre clinical studies) Therapy (clinical studies) Rehabilitation Epidemiology Ethiopatogenesis Other (specify) Indicate further areas of research Type of application Training fellowship Research fellowship Duration 1 year 2 years Host Institution Italy Europe Other continents Sum requested 1 st year 2 nd year

2 Data of the applicant (mailing address) First name Last name Date of birth Birthplace Institution Address Zip Code City Telephone Fax Data of the host Institution Institution Address Zip Code City Telephone Fax Data of the presenter (e.g.: previous tutor, Institute director) First name Last name Position Institution Address Zip Code City Telephone Fax

3 Il richiedente, nel sottoporre la richiesta per un assegnazione, accetta quanto segue: 1) i fondi concessi a seguito della richiesta devono essere usati per lo scopo qui precisato e secondo i regolamenti e le procedure stabiliti dalla F.I.S.M. per le assegnazioni; 2) l assegnazione può essere revocata per intero, o in parte, in qualsiasi momento, dal Consiglio di Amministrazione della F.I.S.M., a condizione che la revoca non includa spese stabiliti prima della data effettiva della revoca, se dette obbligazioni furono fatte esclusivamente per gli scopi stabiliti in questa domanda; 3) tutte le relazioni sulla ricerca, svolte in seguito a questa richiesta, devono citare la fonte del contributo; 4) per ogni scoperta o invenzione brevettabile che sarà conseguita durante il lavoro sostenuto da questo contributo, il richiedente dovrà interessare tempestivamente la F.I.S.M. e si impegna su quanto verrà stabilito dalla F.I.S.M. Per espressa accettazione del Regolamento ed in particolare di quanto sopra richiamato ai punti 1, 2, 3, 4. Date Signatures: Applicant Presenter N.B. La mancata compilazione di questa pagina invalida la domanda

4 Summary of the training or research programme (in English, less than 300 words) Key words (3-5) Riassunto del programma di addestramento o di ricerca proposto (facoltativo - in italiano e non più di 300 parole) Parole chiave (3-5) Riassunto del programma di addestramento o di ricerca proposto, in italiano, usando termini molto semplici e comprensibili da tutti. Tale riassunto, se il progetto verrà finanziato, sarà utilizzato per informazione sui mass media (obbligatorio - non più di 300 parole)

5 Training or research programme (in English; an additional version in Italian is an optional) Instructions: A. Training fellowship: i) description of the training programme and of the background of the applicant (1 page, <5.500 characters, including spaces); ii) brief description of the activities research project to which the fellow will participate in order to be trained as described in i) (< 2 pages, < characters) iii) pertinent references B. Research fellowship: i) Background, scientific rationale and aims of the project (< 2 pages, maximum characters, including spaces); ii) Research proposal and methods (< 4 pages, < characters including space). iii) pertinent references IMPORTANT NOTE: the applicant for a research fellowship must indicate whether the research proposal represents an independent project carried out by the research fellow or a research project of the mentor of which the research fellow will carry out one or more aspects. In the latter case, the applicant should clearly specify and describe what part of the research project he will be in charge of.

6 Data of the Mentor First name Last name Position Institution Address Zip Code City Country Telephone Fax Brief summary of current activities in the Institute of the Mentor, with particular reference to the training or research program of the present application Please, include a letter of acceptation of the Mentor

7 Curriculum vitae of the applicant Academic degree Institution City Year Degree Other degrees Institution City Year Degree Professional activity Position Name and address of employer From To Additional information

8 List of publications of the applicant (last 4 years, not more than 10) Please give complete reference, including all author names, title, journal or book, pages and year of publication. Include a copy of up to 3 publications believed to be important and pertinent to the present application) Previous fellowships or research grants Agency Dates Beginning End Topic Programmes for the future (please, indicate your professional plans when the fellowship will expire, with particular reference to how and where you plan to utilise and exploit the experience acquired)

9 Detailed request for economic contribution (Fill one table for each year Please specify the reason for the request) Annual amount request Estimate of the expenditure for 200_ DESCRIPTION EURO Travel (only overseas) Contribution for the host Institution (e.g. insurance) Other expenses (specify) TOTAL Equipments and services available for the project

10 Applicant profile Signature

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