Expression of Interest Host Institutions: Sadc Srim Exchange Programme

ANNEXURE A

EXPRESSION OF INTEREST – HOST INSTITUTIONS: SADC SRIM EXCHANGE PROGRAMME

Deadline for submission of completed Expression of Interest is Friday 23 October 2015

Please submit the completed form to

(1)Host Institution – General Information

Full Name of Institution:
Country of Institution:
Physical address of Institution:
Hosting office type (mark with an “X”) / Research Management Tech Transfer Either RM or Tech Transfer
Preference for fellow to be hosted / Research Management Tech Transfer Either RM or Tech Transfer
How many exchange fellows is the Institution willing to host?
Is the Institution able to host the exchange fellow(s) during the period December 2015 and December 2016?
Is the Institution willing to consider participating in the exchange programme as a host in 2017?

(2)Host Contact Information

Title: / First Name: / Family Name:
Email address: / Telephone No.:
Name of Department:
Current job title:
How long have you been in this position?: ___years and _____months
Give a short description of your main responsibilities in your current position:
Provide an indication of the type of individual that will be designated the supervisor for the exchange visit, and level of experience

(3)Research Management & Technology Transfer Activities

When was the Research Office/Technology Transfer Office/both established (Month and Year)? In the case where an office has not beenestablished, please providename of the staff member who performs the Research management and/or technology transfer function and the period of time that they have been carrying out such function (if not the same as contact person above) .
What are the primary strategic objectives of your Institutional research management and/or technology transfer strategy/plan?
Please list the key policies that are in place relating to research management and/or technology transfer.
What in your view the areas of strength in your institutional Research Office and/or Technology Transfer Office?
Please indicate what your rationale is for wishing to host a fellow, and what you hope to gain from this.

(4)Institutional Commitment

The ______(name of institution):
Supports the SADC SRIM exchange programme and:
Will ensure that the supervisor/designated host is available and that the visit takes place between November 2015 and December 2016
Will provideaccess to the necessary facilities and support to the fellow(s) to meet the requirements of the programme.
Will develop and execute a structured exchange programme, with pre-determined activities and defined outcomes as required in the programme.
______
SignatureDate
Print Name and Surname:
Job title:
Email:
Telephone number:

(5)Application check list

The following documentation should be submitted: / √
Completed and signed Expression of Interest

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