Application Form
FRIENZ Study Group Tour to New Zealand - Health
19th – 23rd October 2015

Dear Applicant,

Please fill out this form and return it as soon as possible or before 09:00 Friday 31st July 2015 (NZ Time) to Michelle Wickens, Project Officer (FRIENZ) (). Please note our email server cannot receive emails over 6MB in size.

1.  Personal Information

First name / Surname
Organisation
Position
Fields of Specialisation
(research/professional)
Address
City/Post Code / Country
Phone
E-mail

Research Background

2.  Short description of your motivation for attending; include your experience in Living a Long and Healthy Life related research and innovation and current interest in research direction, max 200 words.

3.  Short description of your interest in Living a Long and Healthy Life development in New Zealand, max 100 words.

4.  Short description of your experience in forming national and international collaborations with researchers and companies, include how you might progress any relationships established through the tour, max 200 words.

5.  Potential contacts for the targeted organisations in New Zealand (if any)

Organisation / Contact Name / Tel / email / Your relationship

6.  Curriculum vitae information

Please complete the following:

Academic qualifications

Delete and start typing here. List in reverse date order. Start each qualification on a new line as per the example:

E.g. Year conferred, qualification, discipline, university /institute.

Professional positions held

Delete and start typing here. List in reverse date order. Start each position on a new line as per the example:

E.g. Year to year, job title, organisation.

Total years research experience / years
Top 3 Living a Long and Healthy Life related publications and/or patents / Journal articles / Books, book chapters, books edited / Conference proceedings / Patents
Current and previous research work (maximum 3 contracts)

Repeat and expand box below as necessary.

Research title:
Principal outcome:
Funding organisation and value:
Please provide 3 examples of the commercial, social or environmental impact of your previous research work

Please delete and begin typing here. Provide no more than five examples relevant to your application.