Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015
FWO_ASTRAZENECA_ONCO_2015
Fonds Wetenschappelijk Onderzoek – Vlaanderen To be filled in by the investigating Research Foundation - Flanders department Egmontstraat 5 - 1000 BRUSSEL received date Tel. 02 512 91 10 - Fax. 02 512 58 90 E-mail: [email protected] number file Website: http://www.fwo.be What is the purpose of this form? With this form you can compete for the Scientific Award Foundation AstraZeneca – Oncology 2015. This prize rewards excellent scientific achievements in the clinical and translational research in oncology that lead to personalized care of cancer patients, e.g. through research into biomarkers predicting treatment sensitivity and avoiding side effects. It intends to reward an established investigator on the basis of his/her previous work, with a perspective of future development in the same field. How to submit this form? This form has to be submitted before June 15, 2015, at the e-mail address on top of this document. How does the FWO handle the data in this form? The FWO uses your information only for processing your candidature. The data will be handled confidentially and won’t be disclosed to third parties. As soon as the FWO has processed your application, you will receive a notification message.
Details of the candidate
1 Enter your personal details. first name and surname legal domicile address
private phone department address
work phone e-mail address birthplace
date of birth day month year
nationality gender m f civil status
2 Enter the data of your account number.
IBAN
BIC Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015 - page 2 / 6 3 Give an overview of the achieved university diplomas (incl. PhD diploma).
diploma university date (dd-mm-yyyy)
4 Give an overview of your current and past functions in a biomedical context
function university or institute period (from / till)
Details of the research
Details of the research unit
5 Provide the name of your research unit and the name of the head of the research unit where you conduct your research. name of the research unit name of the head of the research unit
Details of the proposed research
6 Describe the specific scientific domain of your research in three keywords.
7 Enter the English and Dutch title of the proposed project. Use a maximum of 240 characters, including spaces.
Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015 - page 3 / 6
8 Research outline. Maximum 4 pages in English.
Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015 - page 4 / 6
9 Elaborate on the results which the clinical or experimental study might generate in the following three years. Maximum 1 page in English.
Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015 - page 5 / 6
Details of scientific publications
10 Give an overview of your scientific publications and indicate those related to the prize. For each publication, mention the following: - The title, completely without abbreviations - The journal, use only the internationally accepted abbreviations - Date of publication - The number of pages and for publications part of a book or magazine, the reference ‘from page x to page y’; - The names of the authors, according to the presentation order. - The impact factor of the journal - The number of citations for each paper The FWO reserves the right to call for reprints.
Candidature for the Scientific Award Foundation AstraZeneca – Oncology 2015 - page 6 / 6 Other national and international awards
11 Did you already receive a national or international award for the same research? yes no
12 List all national or international awards that you already have received, whether or not for this research. Indicate for each prize the following data: the name, the period, the amount, the aim and the origin, i.e. the organization which provided the award.
Title of the research date amount aim name of the award and origin
euro
euro
euro
euro
euro
Mandatory attachment
13 Enclose the following documents:
a detailed curriculum vitae
Signature
14 Fill in the following declaration.
I hereby confirm that all data and information is correctly filled in.
date day month year
signature
first name and surname