Candidature for the Scientific Award Foundation AstraZeneca – Auto-immune and Rheumatic diseases2014 - page1/6

Candidature for the Scientific Award Foundation AstraZeneca– Auto-immune and Rheumatic diseases 2014 / / /
Fonds de la Recherche Scientifique - FNRS
Rue d’Egmont-1000 BRUXELLES
Tel. 02 504 92 40
E-mail:
Website: / To be filled in by the investigating department
received date
FC / file
2014/P 95/2
Form to return to the Fonds de la Recherche Scientifique – FNRS via the address before June 2, 2014.

Details of the candidate

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 / day / month / year
nationality / gender / m / f
civil status
2 /

Enter the data of your account number.

IBAN
BIC
3 / Give an overview of the achieved university diplomas (incl. PhD diploma).
diploma / university / date (dd-mm-yyyy)
4 / Give an overview of your current and past functions with a biomedical context
function / university or institute / period (from / till)

Details of the research

Details of the research unit
5 / Provide the name of your research unit and the name of the head of the research unit where you conduct your research.
name of the research unit
name of the head of the research unit
Details of the proposed research
6 / Describe the specific scientific domain of your research in three keywords.
7 / Enter the English and French title of the proposed project.
Use a maximum of 240 characters, including spaces.
8 / Give a description of the proposed work.
A memorandum of maximum 4 pages in English.
9 / Give an explanation of the expected results of the clinical & experimental research in the next 3 years.
Maximum 1 page in English.
Details of scientific publications
10 / Give an overview of your scientific publications and indicate those related to the prize.
For each publication, mention the following:
-The title, completely without abbreviations
-The journal, use only the internationally accepted abbreviations
-Date of publication
-The number of pages and for publications part of a book or magazine, the reference ‘from page x to page y’;
-The names of the authors, according to the presentation order.
-The impact factor of the journal
-The number of citations for each paper
The F.R.S.-FNRS reserves the right to call for reprints.
Other national and international awards
11 / Did you already receive a national or international award for the same research described in the memorandum.

yes

no

12 / List all national or international awards that you already have received, whether or not for this research.
Indicate for each prize the following data: the name, the period, the amount, the aim and the origin, i.e. the organization which provided the award.
Title of the research / date / amount / aim / name of the award and origin
euro
euro
euro
euro
euro

Mandatory attachment

13 / Enclose the following documents:
a detailed curriculum vitae

Signature

14 / Fill in the following declaration.
I hereby confirm that all data and information is correctly filled in.
date / day / month / year
signature
first name and surname