Contact

Tel. : 02 504 92 40 (344)

Fax : 02 504 92 10

Foundation AstraZeneca Award for
translational research 2012

IMPORTANT REMARK:

The final date for submitting this form is May 15th, 2012

The ”Fonds de la Recherche
Scientifique - FNRS” always acknowledge
the receipt of a form

Foundation AstraZeneca Award for translational research 2012

FONDS DE LA RECHERCHE SCIENTIFIQUE - FNRS
Rue d’Egmont 5
1000 BRUXELLES / FC / 2012/P 87/2
Date
Tel. : 02.504.92.11
Tel. Prize : 02.504.92.40 (344)
Fax Prize: 02.504.92.10
E-mail Prize : / Form to return to the “Fonds de la Recherche Scientifique - FNRS”
byMay 15th 2012

CONFIDENTIAL

  1. Enter your personal details.
First name and surname
Legal domicile address
Private phone
Department address
Work phone
E-mail address
Birthplace
Date of birth
Nationality
Gender
Civil status
  1. Enter the data of your account number.
/ IBAN :
BIC :
  1. Give an overview of the achieved university diplomas
(diploma, university, date).
  1. Give an overview of your current and past functions with a biomedical context.
(function, university or institute, period)

Foundation AstraZeneca Award for translational research 2012

Page 2
  1. Provide the name of your research unit and the name of the head of the research unit where you conduct your research.

  1. Describe the specific scientific domain of your research in three keywords.

  1. Enter the English, French and Dutch title of the proposed project.
For each title, use a maximum of 240 characters, including spaces.
  1. Have you already received a national or international award for the same research described in the memorandum ?

  1. List all national or international awards that you have already received, whether or not for this research.
Indicate for each prize the following data: the name, the period, the amount, the aim and origin, i.e. the organization wich provided the award.
  1. Enclose the following documents with this form.
-a detailed curriculum vitae,
-a bibliography,
-a memorandum, in English, with a description of the proposed work (max. 4 pages)
-an explanation of the expected results, in English, of the clinical or experimental research in the next 3 years (max. 1 page)
-a list of the relevant scientific research publications.
Specify for each publication:
-the title and journal
-the number of pages and for publications that are part of a book or magazine the entry “from page x to page y”
-the names of the authors, in the same order as mentioned in the publications.
The F.R.S. - FNRS can ask for a copy of the published work.

Foundation AstraZeneca Award for translational research 2012

Page 3
  1. Fill in the following declaration.
I hereby confirm that all data and information is correctly filled in.
Date:
Signature:
First name and surname: