DISCLOSURE FORM

1) I agree to be part of the application proposing the following Transatlantic Network of Excellence(insert network title):

2)I have read the Fondation Leducq Conflict of Interest Policy for applicants and

have no conflicts of interest to declare

have the following conflicts of interest to declare (list where appropriate):

Significant financial interests:

Fiduciary relationships:

Executive positions:

Other:

(check relevant boxes)

3)Please list any previous involvement in Fondation Leducq-supported research:

4)I certify that I am eligible to participate in the fore-mentioned Leducq network according to the rules pertaining to participation in multiple networks. Further, I have fully and to the best of my ability completed this disclosure form.

Name:Date :Signature:

Eligibility rules

Participants in a Fondation Leducq Transatlantic Network of Excellence program must be affiliated with an academic research center, and must have expertise in cardiovascular or neurovascular disease or an appropriate related field. Fondation Leducq will allow the participation of members from institutions located outside of Europe and North America under the following conditions: 1) the institution with which the investigator is affiliated is able to agree to and abide by the financial, intellectual property, and reporting terms of the network Research Agreement (available on the foundation's website, the network can demonstrate a clear benefit from the participation of the proposed members.

The Fondation Leducq has established the following rules for participation in multiple networks supported by the Transatlantic Networks Program:

  • Network members may not participate in more than two Leducq networks concurrently. (This rule applies only to the 5-year term of the grant, and not to any extension period of the grant term.)
  • Investigators are not permitted to submit more applications than the number of programs in which they could participate if all applications were successful. Practically, this means that in any given year:
  • An investigator not currently participating in a Leducq network can submit a maximum of either one application where his/her role will be that of coordinator, or two applications for that of member
  • A member of a current Leducq network, which is expected to continue the following year, can be included in only one application to the foundation.
  • Applicants for the role of coordinator cannot have their name on any other application submitted to the foundation
  • Following the conclusion of the program of which they were the coordinators, investigators are ineligible to apply again to the Transatlantic Networks of Excellence Program as a network coordinator, although they are eligible to participate as a member of another network. An exception is made for network members who, for whatever reason, have taken up the responsibility of network coordinator during the term of the network grant; they may apply to the foundation as the coordinator of a new network.

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