Application for the Oswald Vander Veken Prize - Page1of5

Application for the Oswald Vander Veken Prize - page1of5

Application for the Oswald Vander Veken Prize 2017 /
Fonds de la Recherche Scientifique-FNRS
Rue d’Egmont 5  1000 BRUXELLES
Tel. 02 504 92 11
E-mail: Website: / Date received
number / file

What is the purpose of this form?

With this form you can apply for the Oswald Vander Veken Prize that rewards an originalcontribution to the understanding of tumors of the locomotor apparatus, their causes, their prevention, the diagnosis and/or their treatment.

How to submit this form?

This form has to be submitted, in English, before March 1, 2017 to .

How does the F.R.S.-FNRS handle the data in this form?

The F.R.S.-FNRS uses your information only for processing your application. The data will be handled confidentially and will not be disclosed to third parties.
As soon as the F.R.S.-FNRS has processed your application, you will receive a notification message.

Details of the candidate

1 /

Enter your personal details.

first and last name
legal home address
private telephone number
work address
work phone
e-mail address
birthplace
date of birth / day / month / year
nationality / gender / m / f
civil status
2 /

Enter the details of your account number.

IBAN
BIC
3 / Enter the details of your university degrees.
Please state full and exact designation
name of the degree / English name of the degree / Institution / date(dd-mm-yyyy)
4 / Enter your present occupation along with the coordinates of the according institution.

Details of the submitted research

Details of the research unit
5 / Enter the name and address of the research unit you belong to. Also enter the first and last name of the head of that research unit.
name research unit
head of the research unit
Details of the submitted research
6 / Enter the English title of yoursubmitted research.
Use up to 240 characters, signs or spaces.
7 / Describe the scientific domain of your research in three keywords
8 / Give an executive summary of the submitted research
Your presentation should not exceed four pages.
Details of scientific publications
9 / Give an overview of your scientific publications and indicate those related to the prize.
For each publication, mention the following :
-the title, completely without abbreviations
-the journal, use only the internationally accepted abbreviations
-date of publication
-the number of pages and for publications part of a book or magazine, the reference ‘from page x to page y’;
-the names of the authors, according to the presentation order.
-the impact factor of the journal
-the number of citations for each paper
The F.R.S.-FNRS reserves the right to call for reprints.
National and international awards
10 / Did you already receive a national or international award for the research submitted

yes

no

11 / List all your national and international awards.
Important! Please mention below all awards that you received earlier for your research.
Indicate for each award the following: the name of the award, the date received, the amount, the title of the awarded work and the origin, i.e. the organization which provided the award
name of the prize / date / amount / title of awarded work / origin
euro
euro
euro
euro
euro

Mandatory attachments

12 / Enclose the following documents with this form.

a detailed curriculum vitae + a list of publications with impact factor

Signature

13 / Complete the following statement.
I confirm that any information on this form has been completed truthfully.
date / day / month / year
Signature (handwritten)
first and last name