EHA – JSH Collaborative Exchange Program Application

Application template

1.  Cover page

APPLICANT
Name
MD / Date of Graduation (mm/yyyy)
PhD / Date of Graduation (mm/yyyy)
Current position
HOST INSTITUTION
Department and Institution
Name supervisor / mentor
HOME INSTITUTION
Department and Institution
Name supervisor / mentor

2.  Exchange Proposal (max 4 pages single spaced, font 11)

·  Description of the collaborative exchange proposal

o  Topic of research (focus on different diseases, approaches or techniques unique to county of exchange).

o  Description of Home and Host Institute and their (existing) collaboration

·  Description of how the exchange will be beneficial in further strengthening the (existing) collaboration

3.  Biographical sketch/CVof the applicant or principal applicant (in case of an institutional application or submission on behalf of a research group).

The CV of the applicant should contain all relevant personal and academic information.

Personal information
Last name
First name
Academic degree
Date of birth
Nationality
Institutional address
Phone Nr.
E-mail
Scientific vita
Current position
since (date)
Scientific occupations since graduation (period of time and subject)
Education
Date of the doctorate (as on the doctorate certificate)
Grade of the doctorate
Subject of the doctorate
University / institution at which the doctorate has been obtained
Publication resulted from the doctoral thesis (if applicable)
Date of obtaining the medical license
Clinical year / residency:
Date / subject / institution
Occupations outside of science (medical specialization education, clinical activity, career education)
Other qualifications / further education (e.g. animal course etc.)
Date, signature

4.  Publication List (if applicable)

Original works (first authorship)
Original works (last authorship)
Original works (co-authorship)
Reviews (first authorship)
Reviews (last authorship)
Reviews (co-authorship)

5.  Budget

Travel
Accommodation
Per Diem
Supplies
Total / EURO 10.000 / JPY 1,000,000

6.  Letter of agreement

Date

Dear Reader,

This is to confirm that [APPLICANT NAME, APPLICANT POSITION, OF APPLICANT INSTITUTE] intends to submit an application for award of the EHA-JSH Collaborative Exchange Program.

The proposed exchange project will be [(Working) TITLE].

This project and application are supported by:

[HOME MENTOR NAME, MENTOR POSITION, of MENTOR INSTITUTE]

[HOST MENTOR NAME, MENTOR POSITION, OF MENTOR INSTITUTE]

The applicant has completed all required documents and will submit it by email.

European applicants will submit their proposal to the EHA at

Japanese applicants will submit their proposal to the JSH at

We herewith confirm to be aware of all terms and conditions related to the EHA-JSH Collaborative Exchange Program and, if awarded grant funds, agree to comply with the acceptance conditions.

By signing this letter all signees agree to the terms and conditions for the EHA-JSH Collaborative Exchange Program.

APPLICANT NAME: HOST MENTOR NAME:

Signature: Signature:

Place, date: Place, date:

HOME MENTOR NAME:

Signature:

Place, Date:

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