Application Form s14

68th Lindau Nobel Laureates Meeting Dedicated to Physiology or Medicine 24 June – 29 June 2018

APPLICATION FORM NOTE:

 Before applying please review the application guidelines and eligibility criteria listed at the Academy’s website: www.science.org.au/lindau-nobel-laureates-meeting

 Applications will not be accepted for researchers who (1) will be older than 35 years at the time of the meeting, (2) hold a permanent position or (3) have participated in a previous Lindau meeting.

 Ideal applicants will demonstrate a strong commitment to their principal field of studies and to interdisciplinary work, for example by undertaking double degrees or interdisciplinary projects. 1. Research Office details Institute name

Institute type

Contact at research Name Position office Full postal address

Email address

Phone number

2. Applicant details Title First name Surname

Applicant’s area of specialisation (five words or less)

Organisation

1 68th Lindau Nobel Laureates Meeting | Application Form Department

Full postal address

Email address

Phone number (incl Business hours Mobile area code)

Date of birth

Place of birth

Applicant is an (select one):

Yes Australian Citizen Yes Australian Permanent Resident Yes Other (please specify):

3. Early Career Researcher status Note: Selection will favour students currently undertaking doctoral studies or postdoctoral fellows

Please select one and complete relevant details:

Yes / No Applicant is enrolled in a research higher degree* at an Australian University Institution Degree title Thesis title Date of commencement Expected date of completion Yes / No Applicant has (1) undertaken a research higher degree* and the applicant’s most recent higher degree has been conferred for less than three years and is (2) working in an Australian university, Australian public-funded research organisation or research-focussed institution at the date of the Lindau meeting Institution Degree title Thesis title Date of conferment Current employer Position held Date of commencement of employment 2 *Master of Philosophy (MPhil), Doctor of Philosophy (PhD) or a Postdoctoral Fellowship.

4. Please list awards received, including awards for extra-curricular activities Add extra lines as necessary

Date of award Award name Institute / Award description organisation

5. Please list current and past tutoring experience Add extra lines as necessary

Start and end date Institute / Subject Description organisation

6. Please answer the below questions in the boxes provided. Note: 1000 characters (including spaces) maximum per answer a. Explain the motivation behind your study and / or research. What about this sets you apart from other applicants?

b. What is your capacity to contribute to the 68th Lindau Nobel Laureate Meeting and how will attending the meeting contribute to your career?

c. Please use the box below to provide any additional information regarding your application.

Attachments Please attach the following documents:

1. Curriculum vitae (maximum two pages)

3 68th Lindau Nobel Laureates Meeting | Application Form 2. Recent publication list, including conference presentations (maximum two pages)

3. Letter of recommendation from your academic advisor or internationally renowned scientist, including the specialist scientific expertise of the referee. Note that the letter of recommendation will be forwarded to the Lindau Council if you are nominated by the Academy. A strong letter of support which highlights achievements such as academic excellence, conference publications, tutoring experience, awards received, print publications, extra-curricular activities and any other items of note specific to you is essential. Important notices All below conditions are agreed to by the applicant by submitting the signed application form.

1. Nominations will be considered by an Australian Academy of Science selection panel and a maximum of 10 short-listed nominations will be recommended to the Council for Lindau Nobel Laureate Meetings. The final decision regarding attendance at the 68th Lindau Nobel Laureates Meeting will be made by the Council for Lindau Nobel Laureates Meetings. Decisions are based upon the assessed competitiveness of the application. The Academy is not able to enter into discussion or correspondence regarding the reasons why an application is successful or not.

2. The registration fee for the 2018 meeting is EURO2,500 per attendee. The grant-in-aid will contribute up to AUD3,178 towards this fee for each attendee. The Academy will pay the registration fee at the conclusion of the meeting. If the final figure for the registration fee exceeds AUD3,178 after conversion the attendee must pay the difference to the Academy before 31 August 2018. The applicant agrees to this condition by submitting the signed application form.

3. The program does not provide funds for bench fees, managerial, insurance or visa costs.

4. All successful delegates are expected to attend the Academy’s annual event, Science at the Shine Dome, 21-24 May 2018.

5. All successful delegates are expected to attend the full program of events at the 68th Lindau Nobel Laureates Meeting. Delegates will need to arrive in Lindau before the opening ceremony on Sunday 24 June 2018 and depart after the close of the program on Friday 29 June 2018.

6. The Academy receives funding to organise a series of site visits for the delegation to German laboratories in the week following the Lindau Meeting. Applicants should be available to take up this opportunity if successful.

Please insert electronic signatures below:

Signature of applicant: Signature of contact at research office:

Name: Name : 4 Date: Date:

Submit your nomination form and all supporting documents to [email protected]

Deadline for nominations: Monday 2 October 2017, 5 pm AEDT

For enquiries contact [email protected] or 02 6201 9484

5 68th Lindau Nobel Laureates Meeting | Application Form