Application Form for the
International Partnerships for Science and Technology (IPSAT)
Part I Primary(Local) Applicant
1. PERSONAL INFORMATION(i) Title (check one): Prof. Dr. Eng. Mr. Ms.
(ii)Gender: Male/ Female
(iii)Name(underline family name):
(iv)State the name under which you publish:
(v)Contact details
Postal address:
Telephone:
Fax:
Email:
(vi)STMIS number:
(vii)Country / ies of citizenship:
(viii)Date of birth(day/month/year):
(ix)Current position
Job title:
Institution:
Date of appointment:
(x) Department/office, institution – (name, postal address and e-mail address; telephone
Postal address:
Telephone:
Fax:
Email:
(xi) Academic discipline and sub-fields - list subfields within the broad academic discipline in which you specialise (e.g., biotechnology, bio-fuel)
(xii)Academic credentials - name and location of institution, name of degree, date received (list in reverse chronological order)
(xiii)List your most significant professional accomplishments, honours and awards, and list your significant publicationswithin last five years (attach list if necessary):
(xiv)Previous Research Grants/ projects – list (attach if necessary) your most recent projects, state whether you are (were) the Principal Investigator or Co- investigator, provide dates andindicate status of project.
(x) Information on past and current S&T collaborations (national or international)
(xi) Is the programme a part of an ongoing collaboration with a foreign institution? If yes, please mention the name of the institution and a brief note on the existing collaboration.
(xii) Information on service rendered to the NSF. Please tick as appropriate
Current member of the NSF Committee –
Past member of the NSF Committee –
Reviewer –
Any other –
Please specify (Name of the Committee, period, etc.)
......
......
(xiii) Referees – list the names and contact information of three persons who are familiar
with your work
2. THE ACTIVITY
(i)The activity (workshop / project / programme) for which you are seeking funds
(ii) Duration and dates – indicate as precisely as possible the period during which you
intend to carry out your activity
(iii)Venue - state where the activity will be conducted;(if the activity will not be conducted at your home institution, provide a statement from the Head of that Institution confirming provisions for the activity, ref. Section 5 (iii) & 5 (iv)
(iv) Budget – attach a complete budget, where actual figures are not available, provide
estimate(s) with justification(s).If airfare and accommodation are requested from NSF, two original quotations (per each) in favour of NSF should be submitted. (for airfare - quotations should be provided inclusive of an itinerary from two travel agents licensed by the Civil Aviation Authority of Sri Lanka for a ticket valid for 30 days.).
(v) Alternate funding– list all non-NFS funding you expect to receive for this project and
attach supporting documentation
Description of the activity is the most important component of the NSF application; the attached description should include the following:
(i) Need for the proposed workshop/project/ programme in Sri Lanka
(ii) Expected output and its significance to Sri Lanka
(iii) Expected impact from the activity
a statement in less than 600 words, which allows non-specialists to appreciate the significance of the activity - on how the proposed workshop/ project / programme will contribute towards the advancement of your discipline, its applications in national development and its potential to promote international collaboration.
(iv) How do you propose to implement the activity?
(v) What is the strength of your institution/ department to support this activity?
(vi) Activity plan (with a time schedule)/ action plan
(vii) How do you propose to harness the benefits of the workshop’s/project’s /programme’s output to national (i.e. Sri Lanka’s) development?
(viii) What are the other benefits of the programme (e.g. workshops, seminars, postgraduate degrees, likely patents, publications/ reports)?
(ix) Identify the key performance indicators for your activity
(x) Indicate your follow up activities
4. BIBLIOGRAPHY- please attach a list of references which are relevantto the proposed activity.
5. STATEMENT FROM HEAD OF INSTITUTION- please attacha statement from the Head of your Institution including:
(i)the detailed benefits of the present proposal and its relevance to the home institution
(ii)the potential, as well as facilities available, for future research collaboration between the two institutions
(iii)a commitment to provide institutional facilities including laboratory space / bench space, consumables, access to instrumentation, laboratories and libraries outside standard working hours and throughout the year irrespective of public holidays
(iv)a commitment to ensure purchases required for the activity are made in the shortest possible time
If the activity is not going to be conducted at your home institution, Sections 5 (iii) & (iv) should be completed under Section 2 (iii)
6. THE CURRICULUM VITAE
Please attach your curriculum vitae, which should include the following:
(i)name(according to the National Identity Card), date of birth, nationality and contact details
(ii)education (universities attended, degrees earned and dates)
(iii)employment history and positions held
(iv)courses taught, projects supervised for graduate students and other services provided to the student / academic community
(v)ongoing research projects and those completed within the past 5 years
(vi)publications within last five years(provide full citations and list them in reverse chronological order)
(vii)patents held in your name
(viii)other professional activitieswithin last five years, such as workshops, seminars and membership and activities in professional associations
(ix)professional honours, awards and fellowships
(x)civic or community service
While this application form asks for similar information as in category 1, the latter provides limited space for answers. In the curriculum vitae, you should expand upon these topics to illustrate your accomplishments.
7. THE CONSENT OF RESOURCE PERSON/S
Please attach the consent of your resource person/s (email/s or letter/s)
8. SIGNATURES
By our signatures below, we certify that, to the best of our knowledge, the information provided in all parts of this application is accurate and complete.
......
Name of Primary Applicant Name of Head of Institution/Department of Primary Applicant
......
Signature of Primary ApplicantSignature of Head of Institution/Department of
Primary Applicant
DateDate