KyotoUniversity Global COE Program

“Center for Frontier Medicine”

Travel AwardApplication Form 2012

The Second Term

INSTRUCTIONS

1. Application should be typed in English.

2. Years should be written in the Anno Domini system.(e.g.,Aug 1, 2012)

3. Proper nouns should be written in full.

Date: mmdd, 2012

1. Name in full

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

2. Age,date of birth, nationality and sex

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

3. Home address and contact information

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

*E-mail address insideKyotoUniversity is preferable.

4. Affiliationand contact information

Major / Department/Organization / Grade/Title
1.Medicine(Doctoral Course)
2.Medical Science(Doctoral Course)
Telephone (Ext.) / Fax
( )

5. Contact information of administrative assistant (secretary) in your laboratory

Name / E-mail address
Telephone(Ext) / FAX

6. Educations

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

Name of qualifications / Year and month of acquisition

7. Employment record (including RA, TA and G-COE Fellows / Awards)

List the most recent employmentfirst. (Add more columns 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:

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 oneat least)

* Note that all recipients are expected to participate actively in the course activities (monthly meetings, annual retreats, etc.) and report their experiences as requested by course organizers.

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 the meeting

Name of the meeting / Duration of the meeting
mm/dd/20yy ~ mm/dd/20yy
Name of organizationand organizer(s)
Venue
City / State / Country
Fromhowmanycountries participants are attending? / Name the countries.
Total number of
participants / Prominent participants
Scope of the meeting and expected outcome of your participation

11. Category of your presentation (Circle one)

1) Invited lecture
2)Poster presentation / 3) Workshop / Symposium
4) Others (specify)
( )

12. Outline of your presentation

Title
Abstract

13. Publicationsand Presentations

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

2) Presentation (oral or poster)at international or domestic conferences. (Add more columnsto the table if necessary.)

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

14. Itinerary

Period
Mon dd, 20yy ~ Mon dd, 20yy
Itinerary
Date / Place of departure/arrival / Site/ Venue / Length and place of the stay / Purpose/ Activity
(example)
Oct1,2012
Oct 6, 2012
Oct 7, 2012 / Kyoto
↓
Itami (8:00)
↓
Narita (9:10)
Narita(11:25)
↓
Frankfurt(16:30)
(Am Main Int’l airport)
Frankfurt (18:30)
↓
Geneva (Cointrin Int’l airport) (19:35)
Geneva(18:35)
↓
Frankfurt(19:50)
Frankfurt(20:45)
↓
Narita(15:00)
(Oct 7, 2010)
Narita(16:40)
↓
Itami(17:55)
↓
Kyoto / Transit
Transit
(Venue)
Geneva Convention Centre
Transit
Transit
(flying overnight) / 4 nights(Oct 1-5)
(Stay at:
Hotel Geneva) / Participating in 11th ABC Congress (Oct 2-6)
Including my presentation (Oct 3)

15. Recommendation

Recommendation
Comments:
Priority: ( ) among ( ) total candidate(s) from the department
Department:
Title: Name:
Signature: Date:

16. Attached documents

I attach (number: ) document(s), ( )page(s) in total, relevant to my participation in the meeting (e.g. a copy of invitation letter, acceptance letter, programpages, web pages, etc.)

17. Other subsidy

Do you receive any subsidy from any other sources? YES / NO

If your answer is YES, provide the following information:

Name of the source:

Transportation (amount):

Accommodation (amount):

Others (item and amount):

I understand the purpose and conditionsof theTravel Award stated in the guidelines, and I submit this application form to attend the aforementioned international meeting as a delegate of the GCOE of Kyoto University and will strive to do my utmost to adhere to its high ethical standards.

Date of application：

Signature:

Name (type):

pg. 1

Applicant’s name