1. Table of Contents
Indicate below the page number(s) of each applicable section of this application.
Table of Contents...... 1
Title Page...... 2
Account of work/Summary...... __
Biographical Sketches ………………………..……….………………………………………………………….__
Current, Pending and Past Research Support...... __
Publications List...... __
Future Research Plan...... __
Research Facilities Available...... __
Candidate’s Statement...... __
2. Title Page:
Indicate the title of your project and your hosting institution, including contact information for the applicant and his/her hosting institution.
Project Title:
Hosting Institution:
Applicant:
Last Name:First Name:
Degrees:Year(s) Granted:
Title/Position:Appointment Date:
Department:
Address 1:
Address 2:
City:Postcode:Country:
Email:Phone:Fax:
Hosting Institution (Division/Department Head)□
Last Name:First Name:Middle Initial:
Title/Position:Appointment Date:
Department:
Address 1:
Address 2:
City:Postcode:Country:
Do you plan to retire within the next 5 years?
I certify that the information contained in this application is correct to the best of my knowledge. I also understand that if any information is falsified, my application may be disqualified.
Name ______Date ______
3. Account of work/Summary:
In the space below, please describe major achievements and how these have changed the field in terms of knowledge of basic mechanisms and/or clinical practice. It is important that you stress the importance of your work to clinical gastroenterology or hepatology. This summary should be in language which is easy for a practicing clinician to understand. (A modified account must be presented by the prize winner at the next UEGW Plenary session)
4.Biographical Sketches:
Provide the following information for the applicant. Limit to one (1) page.
Last Name, First Name / Position/TitleEducation/Training: Begin with initial professional education and include post-doctoral training.
Institution and Location / Degree (if applicable) / Year(s) / Field of StudyResearch and Professional Experience: Starting with present position; list, in chronological order, previous employment, experience and honors.
PROFESSIONAL EXPERIENCE
Dates / Title / Mentor / Institution and LocationRESEARCH PRIZES
5. Publications: List, in chronological order, the titles, all authors and complete references of the 10 major original research publications in the past 5 years and a maximum of 5 earlier original research publications. Do not include reviews or opinion pieces. Limit to two (2) pages.
6. Current, Pending and Past Research Support: Include all active or pending support (governmental, institutional, for-profit, not-for-profit or other grants from research councils) available to the applicant and collaborators (if applicable). List title, funding agency, total direct costs and dates, including expected date(s) of notification of pending applications for all current and pending funding.Limit to a total of two (2) pages.
I. Current support: (should list all current grants):
II. Pending support (should list all pending applications):
III. Substantial past support:
7. Future Research Plans to be funded with this prize: Please use the headings: title, specific aims, background and clinical significance, preliminary data and research plan. This section should include sufficient information needed for evaluation of the project independent of any other document. Be specific and informative and avoid redundancy. Limit to two (2) pages.
8. Research Facilities Available: List office, laboratory, major equipment, support staff and clinical facilities available. Limit to half a page.
9. Applicant’s Statement: Describe the benefits of this award to your research career and the impact the award will have on your research development. Limit to half a page.
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