2013Brain Tumour Research Grant Application Form: Brain Tumour Foundation of Canada

2013Brain Tumour Research Grant Application

  1. Principal Investigator’s Name:

Title and Position:

Work Mailing Address:

City:Province:Postal Code:

  1. Present Position:

Department:

Institution:

Mailing Address:

City:Province:Postal Code:

E-Mail Address:

Phone:Fax:

  1. Institution where research will be done:

Address:

City:Province:Postal Code:

  1. Outline your role as applicant for this project:
  2. Title of Proposed Research:

5a: Please indicate the type of research you will be conducting. Please refer to page 1 of the “2013 Outline & Guidelines” for definitions.

Basic Research

Clinical Research

Translational Research

5b:Please mark with a check beside all topic areas that relate to your proposed research. This information is to help us facilitate the review process.

Angiogenesis

Apoptosis/Cell Death

Cell Cycle

Cell Signaling

Cellular Differentiation & Transformation

Chemotherapy & Experimental Therapeutics

DNA Damage Repair

Drug Delivery

Epigenetics

Gene Expression/Transcription

Gene Therapy & Viral-Based Therapies

Genetics

Imaging

Immunology/Immunotherapy

Invasion/Motility

Proteomics

Quality of Life

Radiation Therapy

Stem Cells

Other

5c:Is this project pediatric focused? Please note that all pediatric projects will be processed separately.

Yes

No

  1. Has this project been submitted for review by your institutional ethic review board?

No, not applicable (No human and/or animal subjects)

Yes, approved (copy of approval notice attached)

Yes, approval pending

Not yet submitted

  1. Budget Total $ Requested:Note: Provide a detailed breakdown showing justification of the budget on page 4 of this document.

7a: Have you applied, or do you intend to apply, elsewhere for salary support? If yes, please explain:

7b: Other funds applied for:

7c: Other funds received:

Please be brief and follow the instructions for the following sections.

  1. Please provide a brief summary of your project that can be used for publications of Brain Tumour Foundation of Canada. Please describe the implications of this research project for brain tumour patients. Maximum – 200 words. Designate as Attachment #8
  2. Please attach a mini Curriculum Vitaefor the principal applicantfor the last five (5) years only. Maximum – two (2) pages. Designate as Attachment #9
  1. Please provide an outline of the research on not more than three (3) attached pages using TIMES ROMAN 12 POINT FONT. The outline will be rated on the following six points:
  1. Purpose of the research
  2. Background information
  3. Formulation of the objective of hypothesis
  4. Research design
  5. Expectations
  6. Possible pitfalls
  7. References if appropriate

Designate as Attachment #10

IMPORTANT: As much as possible, the outline of the research should be written in lay terms. The members of the Research Committee of Brain Tumour Foundation of Canada, who will be reviewing the grant applications, are from many different backgrounds: medicine, industry, business, philanthropy etc. If you feel it is necessary to use complex terminology, please try to explain the terms as much as possible. The Research Committee may also seek the help of outside reviewers if it is deemed necessary.

Budget Breakdown

Title of Project:

Provide a general description of the budget needs of this project:

Provide a detailed description of the budget needs of this project in the table below:

Item / Details / Amount Required

All funds are paid to the order of the institution and mailed to the institution’s business/finance office directly. In the event that you are awarded funds for your project, the following information is needed to help us process the award in a timely manner.

Name of contact at the Institution’s Business/Finance or Accounting Office:

Contact’s Title:

Contact’s mailing address:

Contact’s Phone Number & Email address:

Institution’s CRA Business Number:

Also, please provide the contact information for media inquiries for your institution:

Applications that are incomplete or that do not conform to the guidelines will not be reviewed.

Note that signature by the Principal Investigator/applicant attests to the fact that all the statements made in the application are true.

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Signature of Principal ApplicantDate

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Name of Principal Applicant (print or type)