ESSM-SMSNA Joint Travel Fellowship Application Form
TITLE OF STUDY:
Name and surname of the applicant:
Current position:
Address:
E-mail:
Phone:
Fax:
Member of ESSM ☐
Member of SMSNA ☐
Name and surname of supervisor at home institute:
Current position:
Address:
E-mail:
Phone:
Fax:
Member of ESSM ☐
Member of SMSNA ☐
Name and surname of supervisor at host institute:
Current position:
Address:
E-mail:
Phone:
Fax:
Member of ESSM ☐
Member of SMSNA ☐
Proposed start date:
Proposed end date:
Duration (in months):
SUMMARY (max 300 words):
Please summarise the background, aims, methods and expected impact in simple terms
BACKGROUND (max 500 words):
AIMS (max 200 words):
METHODS (max 300 words):
REFERENCES:
IMPACT (max 500 words):
What would be the impact of the project on sexual medicine field when it is successfully completed? Please explain how this travel fellowship will aid you with your career aspirations in sexual medicine field. Please feel free to speculate how this project will be continued following your return to your home institute after successful completion of this fellowship
ETHICAL AND REGULATORY PERMISSIONS:
Please explain the ethical and regulatory permissions already obtained or to be obtained for (if applicable):
1) Animal research
2) Human tissue
If the permissions have not been obtained already, please give timelines of when they are expected to be obtained and how obtaining such permissions will affect the overall project timelines.
BUDGET:
Please give a detailed and itemized budget, see T&C for eligible and ineligible costs
ATTACHMENTS:
Please attach:
CV of the applicant including list of all peer reviewed publications
Support letters from the supervisors at home AND host institutes
SIGNATURES:
I have read and understood the ESSM-SMSNA Joint Travel Fellowship Terms and Conditions and agree that if my application is successful, I will abide by them.
Applicant:
Name, surname:
Signature:
Date:
I confirm that I have read this application and that, if granted, the work will be accommodated and administered in this Department/Institution in accordance with the ESSM-SMSNA Joint Travel Fellowship Terms and Conditions. I confirm that the resources necessary to support the applicant and this research are available within the Department/Institution.
Head of Department
Name, surname:
Position:
Signature:
Date:
Administrative Authority:
Name, surname:
Position:
Signature:
Date:
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