MDC Funding Application

MDC FUND REQUEST FORM General Information PRIMARY INVESTIGATOR: DATE OF APPLICATION: Email: Phone:

MENTOR (If Fellow/Resident/Student): AMOUNT REQUESTED (up to $10,000):

CO-INVESTIGATOR(S):

PROJECT TITLE:

EXPECTED PROJECT DURATION: Start date: ______End date: ______Project Details SIGNIFICANCE AND SPECIFIC AIMS (1 page):

HOW WILL PROJECT FORWARD THE MISSION OF THE MOVEMENT DISORDERS CENTER? (1/2 page)

PROJECT OBJECTIVES/METHODS (2 Pages):

FUTURE DIRECTIONS OF THIS RESEARCH (1/2 Page): [Type text] [Type text] [Type text] LITERATURE CITED: (1 page)

TIMELINE, BUDGET AND BUDGET JUSTIFICATION (1 Page):

P.I. Signature: ______Date: ______

Date Discussed by committee: ______

Committee members:

Approved by committee majority vote? ☐ Yes ☐ No If no, committee requests additional information or revisions before considering for funding? ☐ Yes ☐ No

☐ Project not appropriate for use of MDC funds.

Notes/Comments (include requests, questions, feedback for applicants; may include suggestions for project regardless of funding decision. Also if there are improvements to be made to this form and application process.):