Osteogenesis Imperfecta Foundation, Inc

Osteogenesis Imperfecta Foundation, Inc.

804 West Diamond Ave., Suite 210

Gaithersburg, MD 20878

(301) 947-0083

Fax: (301) 947-0456

APPLICATION FOR RESEARCH FELLOWSHIPS

INSTRUCTIONS FOR COMPLETING APPLICATION

1. FY 2007 funding will include:

• Michael Geisman Fellowships: Applicants must be in academic institutions and the work must be done under the supervision of a mentor with training and experience in osteogenesis imperfecta (OI) or a related field. Fellowships may be funded at up to $50,000 per year ($35,000 toward the investigator’s salary and up to $15,000 per year for supplies). Funding may be available for second-year support. Fellowship applications must include a letter from the applicant’s mentor, in which the mentor pledges support for the applicant and assesses the applicant’s qualifications; and a copy of the mentor’s curriculum vitae. Reference letters are required by the application deadline.

1. Please submit the original and 10 copies of your application to the following address NO LATER THAN NOVEMBER 1, 2005.

OI Foundation

Attn: Research Grants

804 West Diamond Ave., Ste. 210

Gaithersburg, MD 20878

OSTEOGENESIS IMPERFECTA FOUNDATION

APPLICATION FOR RESEARCH FELLOWSHIPS AND GRANTS

I am applying for a Michael Geisman Research Fellowship.

TITLE OF RESEARCH PROJECT:

APPLICANT INFORMATION

Name (Last, First, M.I.) Social Security Number:

Address:

City:State:Zip Code:Daytime Phone:

E-mail address:

Educational Information (List in reverse chronological order, starting with your most recent course of study).

Institution/Location / Dates of Attendance / Degree Received / Area of Study

Professional Information (Arrange in reverse chronological order, starting with your most recent employment).

Institution/Location

/ Position/Title / Dates

INSTITUTION AND SUPERVISOR INFORMATION (Supervisor information is required for fellowship applicants)

Name of Current Institution/Employer:

Address:

City:State:Zip Code:

Name of Current Supervisor (include his/her title and degrees):

Current Supervisor’s Phone:

Complete the following section only if you are proposing to conduct research at a different institution:

Name of Proposed Institution/Employer:

Address:

City:State:Zip Code:

Name of ProposedSupervisor (include his/her title and degrees):

Proposed Supervisor’s Phone:

GRANT/FELLOWSHIP NOTIFICATION REQUIREMENTS

Grants and contracts official to be notified if an award is made:

Name:Title:

Address:

City:State:Zip Code:Phone:

REFERENCES (For Fellowship Applicants – not required for Seed or Clinical Seed Grants)

Applicants are responsible for obtaining three letters of reference from people who are familiar with the applicant’s work. The letters may be included with this application or mailed under separate cover. They must arrive at the OI Foundation by the application deadline. Please list the names and contact information for your three references.

1. Name:Title:

Address:

Phone:

1. Name:Title:

Address:

Phone:

1. Name:Title:

Address:

Phone:

RESEARCH ABSTRACT

Please explain your proposed research project in no more than 250 words. Some of the people who will review this application are familiar with OI, but are not trained scientists. Therefore, please use language that is appropriate for a lay audience.

PREVIOUS RESEARCH EXPERIENCE

In no more than 500 words, please explain your previous research experience. You may attach a resume or curriculum vitae listing your research experience if you prefer.

PUBLICATIONS

Please list publications that you have authored or to which you have contributed. Please separate peer-reviewed publications from others. You may attach a resume or curriculum vitae listing your publication experience if you prefer.

RESEARCH PLAN

Please describe your research plan, making sure to cover the following topics.

Research objectives
Background information on the problem/question/hypothesis you will address in your research
Methods and procedures you will use to reach your objectives
The relationship of your work to osteogenesis imperfecta

You may attach additional sheets if necessary, but please limit your description to no more than four pages.

BUDGET

Please attach a separate budget narrative to explain and justify any unusual budget items.

I. Personnel

/

Amt. Requested

from OIF

/ Amt. Requested from Other Source or Donated /

Total Expenses

II. Equipment

III. Supplies

IV. Other

TOTAL

If you have requested funding from other sources for THIS research project, please list the other sources here or on the following page:

APPLICANT’S STATEMENT

I certify that to the best of my knowledge and belief, all of the statements and information contained herein and on any attachments are true, correct, complete, and made in good faith.

I authorize the Osteogenesis Imperfecta Foundation, Inc., (“OIF”) to investigate all statements and/or information contained herein and to contact those people listed as references for the purposes of obtaining any and all information concerning my previous employment and educational background as necessary for arriving at an award decision.

Applicant’s Signature:Date: