Kyoto University Global COE Program

“Center for Frontier Medicine”

Associate Fellowship (AF) Application Form 2012

-Additional Recruitment-

Date: , , 2012

INSTRUCTION

1. Type in English.

2. Spell out all proper nouns (e.g., country, institution).

1. Name in full

Family name / First name / Middle name / Maiden name
Romanblock
letters
Chinese characters
if applicable
(漢字氏名)
Seal or signature

2. Age,date of birth, nationality and sex

Age / Month / Date / Year / Nationality / Sex
19 / Male / Female

3. Home address and contact information

Present address and postal code / Mobile phone
Telephone / Fax / E-mail address
( )

*E-mail address inside Kyoto University is preferable.

4. Present affiliationand contact information

Course/Title / Department/Organization / Grade/Year
1.Medicine(Doctoral Course)
2.Medical Science(Doctoral Course)
3.Research Fellow/Research Student
(研修員/研究生)
4. Others:
Secretary / Telephone / Fax / E-mail address

5. Educations

-Educational background (Add more cells to the table if necessary)

Name and location(City, Country) of school / Year and month of entrance andcompletion / Major subject / Diploma or degree awarded
Undergraduate
Graduate (Master)
Graduate (Doctor)
Others

-Other qualifications (Add more cells to the table if necessary)

Name of qualifications / Year and month of acquisition

6. Employment record (Include RA and TA career)

List the most recent one first. (Add more cells to the table if necessary)

Name of organization / Location
(City, Country) / Period of employment (year and month) / Position/Title / Type of work
From:
To:
From:
To:

7. Do you have any outside duties or part-time jobs as a medical doctor?

(If so, how many days a week?)

Yes ( days/week) / No

8. Research Areaof your choice at CFM (Circle one)

1) Allergy and Immunology
2) Cancer
3) Aging and Lifestyle-related Diseases / 4) Neuroscience
5) Regenerative Medicine

9.Course(s)of your choiceat Graduate Courses for Integrated Research Training

(Circle at least one)

* Note that all AFs are expected to participate actively in the course activities (monthly meetings, annual retreats, etc.) and fulfill the duty when nominated as an Assistant Coordinator.

1) Cell and Developmental Biology
2) Immunology, Allergy and Infection
3) Cancer
4) Genetics and Genome Medicine
5) Neuroscience / 6) Metabolic Syndrome, Aging and Metabolic Medicine
7) Regeneration Medicine and Organ Reconstruction
8) Pathology and Pathophysiology
9) Clinical Research
10) Public Health
11) Medical Engineering and Physics

10. Outline of research plan

1) Project title
2) Purpose. Include backgrounds and present status of your research field and how your research contributes to the field. (Maximum: 100 words)
3)Research plan (Maximum: 300 words)
4) The reason why you are applying for the fellowship(Maximum: 300 words)

11. Publications

1) Articles published or in press in peer-reviewed scientific journals
Include all the authors (underline your name), title, journal, volume, pages, and year

2) Presentation (oral or poster)at international or domestic conferences.

(Add more cells to the table if necessary)

Year, month and date / Name of the conference / Venue / Title of the presentation / Authors (Underline your name)

12. Retreat in Awaji Island on October 5-6, 2012

In principle, you must participate in the G-COE Retreat to make a poster or oral presentation as it is one of your important assignments.

Are you sure about your participation? YES / NO

If your answer is NO, because of an urgent business etc., please describethe reasons for your absence below. It will be evaluated on a case-by-case basis.

13. Recommendation

Recommendation
Comments*:
□ The applicant gave up the previous application due to her maternity matter.
(Check the box if necessary)
Ranking: ( ) among the ( ) total applicant(s) from the department
Department:
Title: Name:
Signature: Date:

*State the reason in “Comments” why the applicant needs financial support from G-COE.

pg. 1

Applicant’s name