Letter of intent



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LETTER OF INTENT

SPECIAL PROJECT AWARD


TITLE OF PROPOSED PROJECT (This space may contain 100 characters, including spaces.)

Please ensure you have checked the website for the program’s research priorities and excluded topics, see http://bayer-hemophilia-awards.com/about_the_program/?view=research_priority




2a. NAME OF APPLICANT (last, first, middle, title)


2b. QUALIFICATION(S)

2c. DATE OBTAINED

2d. DATE OF BIRTH

1.

Month/Year

2.

Month/Year

2e. MAILING ADDRESS (street, city, state or province, postal code, country)


2f. TELEPHONE / FAX (country code, area code & extension)

2g. EMAIL ADDRESS

TEL:

FAX:

3. APPLICANT INSTITUTION / ORGANIZATION

Name


Mailing Address (street, city, state/province, postal code, country)

4. FINANCE OFFICER TO BE NOTIFIED IF AWARD IS MADE

Name


Title

Address


Tel FAX

E-mail



5. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION

Name


Title

Address


Tel FAX

E-mail



6. PRINCIPAL INVESTIGATOR / PROGRAM DIRECTOR ASSURANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge. I agree to accept responsibility for the scientific conduct of the project and to provide the required progress reports if a grant is awarded as a result of this application.

INSERT NAME HERE:



7. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my knowledge.

INSERT NAME HERE OF INDIVIDUAL NAMED IN SECTION 5.





PROJECT ABSTRACT

TITLE OF PROPOSED PROJECT (This space may contain 100 characters, including spaces.)

PROJECT DURATION (1 or 2 years)




START DATE:

FINISH DATE:


DESCRIPTION

The abstract must explain the scope and design of the project together with the rationale, objectives and summary of methods and expected results. The abstract will be judged on scientific merit, innovation, clinical/scientific impact and quality of research environment.


DO NOT EXCEED 500 WORDS.



% OF TIME DEDICATED TO PROJECT (APPLICANT)


ESTIMATE OF REQUESTED FUNDING IN US DOLLARS

$###,###.00 Also write amount in words:

APPLICANT’S ABBREVIATED BIOGRAPHICAL SKETCH (DO NOT EXCEED 2 PAGES)




NAME OF APPLICANT


POSITION TITLE


EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)

INSTITUTION AND LOCATION

QUALIFICATION OBTAINED

(if applicable)



YEARS (e.g. 1995-2000)

FIELD OF STUDY











POSITIONS AND HONORS (List in chronological order previous positions, concluding with your present position. List any honors. Include present membership on any advisory committees No more than 10 in total.)


SELECTED PUBLICATIONS (in chronological order, no more than 10). Do not include publications submitted or in preparation.




SUBMITTING THE APPLICATION

Once you have completed this proposal form, please email it to the Program Administrator at
bayer-hemophilia-awards@bayer.com AND to bayer-hemophilia-awards@porterhouse.biz. Please note that if you wish to attach additional information, e.g. figures and graphs, you must cut and paste them into this document. The administrator will only accept a single Word or PDF document, not several individual items.
By submitting this application, you are confirming that the information you provided is correct and has not been falsified in any manner. If it is discovered that you knowingly provided false information, Bayer Healthcare will consider your application withdrawn and will, if appropriate, take other action.




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