<p> EASO Award Application Form</p><p>The deadline for receipt of completed award application forms is 9th December 2012 – late submissions will NOT be considered. All application forms MUST be submitted by email:</p><p>E-mail: [email protected]</p><p>You must save your application form as follows: EASO Award Application – INSERT SURNAME. For example: EASO Award Application – SMITH.</p><p>Personal details:</p><p>First name(s) Surname: Address:</p><p>Telephone(s): Email: Nationality: Date of Birth: Gender: Member National Association (see EASO website for a list of Member Associations):</p><p>Please indicate which award you would like to apply for (application can be for more than one award):</p><p>Young Investigator Award for Basic Science Young Investigator Award for Clinical Research Young Investigator Award for Public Health Young Investigators United Best Thesis Award EASO Travel Grant</p><p>I am applying for a Young Investigator Award. Should I be successful, I hereby agree to submit a paper to Obesity Facts within 3 months of ECO2013</p><p>Please tick below, additional items submitted with your application:</p><p>A signed letter of approval from your Supervisor </p><p>Additional evidence provided with this form to support your application</p><p>A copy of your thesis (Young Investigators United Best Thesis Award only) 1 Award application:</p><p>Please justify in no more than 300 words why you should receive the EASO award, for which you are applying. Please see the EASO website (www.easo.org) for guidance.</p><p>Evidence of your most important publications, awards and involvement with your National Obesity Association should be highlighted. Please attach documents that you feel would be relevant to back up your application (e.g. full publication list). </p><p>(300 words)</p><p>Work Experience (most relevant and recent):</p><p>Dates: Occupation or position held: Main activities and responsibilities: Name and address of employer: Type of business or sector:</p><p>Education and Training (most relevant and recent):</p><p>Dates: Title of qualification awarded: Principal subjects/ occupational skills covered: Name and type of organisation providing education and training: Level in National or International classification:</p><p>N.B: If you do not receive receipt of your application within 48hrs of submission, please contact the EASO Secretariat.</p><p>2</p>