PETER MORGANE & CARMEN PETTAPIECE

STUDENT RESEARCH FELLOWSHIP

APPLICATION FORM

Deadline for submission: April 5, 2017, 11:59 PM

Applicant Information
Name: / Class Year: / Email:
Consider my application only for the:
(Check one)
Morgane Pettapiece
OR
I would like to apply to both / IMPORTANT: If you checked you would like to apply to both Fellowships and your application is successfully reviewed by both Committees, which Fellowship do you want?
(you can only be awarded one) / Morgane Pettapiece
Have you received either the: Peter Morgane Research Fellowship or Carmen Pettapiece Fellowship before? Yes No / If Yes, which year(s):
Primary Mentor Information
Name: / Title: / UNE affiliation or home institution:
Phone: / Email: / Fax:
Project Information
Title of the Project:
Key words (Specific words or phrases that can be used to index your research project; no more than 3):
Where will you conduct the research? (Room/building, Institution, City, State):
Will human or animal subjects be used in the project? Human Animal N/A
Note: All personnel have to complete the required CITI training prior to participating in the proposed project.
Has the required protocol been approved by either IRB or IACUC? Yes No / If Yes, please provide the protocol #: / If No, please explain (i.e., review pending or to be submitted):
Please list all required training that needs to be completed in order to conduct the project (please consult with your mentor) and the status for each (date to be completed, or date for completion if you already completed the requirements):
e.g., at UNE, the “Laboratory Safety Training” is required for everyone who works in a research laboratory.
Note: All training courses have to be completed by the date(s) specified in order for a fellowship recipient to receive payment.
1.  CITI online training modules for research with human subjects or animals (if appropriate) – by June 5, 2017
2.  MSUCOM Research Training - by June 5, 2017 (Required for Peter Morgane Fellowship)
Please list any additional required training identified by your mentor:
3. 
AGREEMENT REGARDING FUNDS RECEIVED AS A RESULT OF THIS APPLICATION
The undersigned agree to:
1.  Complete the project as outlined herein and fulfill all requirements outlined in Section V in “REQUIRMENTS FOR RESEARCH FELLOWSHIP RECIPIENTS”
2.  Observe institutional responsibilities concerning the protection of animal or human research subjects.
3.  Adhere to all training requirements and related institutional policies when conducting a research project at a selected institution.
4.  Abide by Section VI. FUNDING MECHANISMS in the Timeline and Applications Instructions document.
Applicant Signature: / Date:

Research Proposal – Please refer to the “TIME LINE & APPLICATION INSTRUCTIONS” for details.

Please use “Times New Roman” Font 11 with 1” margin all around and DO NOT exceed the space limitations indicated for each section.

1.  Background/Significance and Specific Aims (up to one page)

2.  Experimental Approach (up to 1¾ pages)

3.  Time Line of the Project (up to ¼ page)

4.  Literature Cited (not exceed one page)

ADDITIONAL MATERIALS:

·  Applicant’s CV

·  Primary Mentor’s Letter of Support

·  Primary Mentor’s Checklist Agreement (Morgane Fellowship Applicants Only- Appendix A)

·  Primary Mentor’s CV or NIH Biosketch

APPLICATION SUBMISSION:

Deadline is 11:59 pm April 5, 2017

All components of the application should be arranged in the following order, converted into a single PDF file, and sent electronically to Diane Labbe at .

CHECKLIST:

Application Form

Research Proposal – per instructions above

Applicant’s CV

Primary Mentor’s Support Letter

Primary Mentor’s Agreement (Morgane Fellowship Applicants only – Appendix A)

Primary Mentor’s CV or NIH Biosketch

NOTE: For Peter Morgane Fellows ONLY: If there is a Co-Mentor, be sure to include the Co-Mentor’s Support Letter, Co-Mentor’s Agreement, and his/her CV/NIH Biosketch AFTER the Primary Mentor’s documents.

2

Revised: 3/9/2017