KyotoUniversity Global COE program

“Center for Frontier Medicine”

IFOM-KUJoint WorkshopApplication Form

Date: mmdd,2012

INSTRUCTIONS

1. Application should be typed in English.

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

3. Proper nouns should be written in full.

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 as of April 1, 2012,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 as of April 1, 2012

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, TAand 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. Your main research area(Circle)

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

9.Graduate Course(s)that you participate (Circle)

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 your presentation

1) Title
2) Abstract (Up to 300 words)

11. 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) Presentations (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)

12.Recommendation

Recommendation
Comments:
I recommend as a young representative participating in the IFOM-KU Symposium 2012.
Priority: ( ) among ( ) total candidate(s) from the department
Department:
Title: Name:
Signature: Date:

13. Purpose of this application

I am submitting this form to apply for the special travel award supporting participants in the 1st IFOM-KU Joint Workshop to be held in Milan, Italy, 25-26 October 2012.

If selected, I intend to attend this symposium as a representative of Kyoto University Graduate School of Medicine, to present a poster on my own study, and to actively participate in the discussions.

Date of application：

Signature:

Name (type):

pg. 1

Applicant’s name