<p> FORM 1A – page 1</p><p>APPLICATION FORM FOR DOCTORATE RESEARCH GRANT</p><p>1 FORM 1A – page 2 APPLICATION FORM FOR DOCTORATE RESEARCH GRANT </p><p>Title of Research </p><p>Scope of research 1. Nutrigenomic 2. Dietetic and Clinical nutrition 3. Community and Public Health nutrition 4. Food Security and Policy Name of student (PI)</p><p>Academic degree/ title (university) </p><p>Name of current institution (where you are studying)</p><p>Name of faculty </p><p>Name of department </p><p>Name of home institution (please indicate department & faculty) Address of Home Institution </p><p>Name of advisor(s) </p><p>Name of institution of advisor </p><p>Address of institution of advisor </p><p>Contact address of PI Telephone</p><p>Fax</p><p>E-mail</p><p>Mobile </p><p>Mail address</p><p>Research Title </p><p>Propose starting date of research (dd/mm/yy) </p><p>Propose end date of research (dd/mm/yy)</p><p>Total grant requested (in Rp)</p><p>Date of application </p><p>Reason for applying</p><p>2 [TITLE OF THE PROPOSAL] </p><p>[SUMMARY OF THE PROPOSAL] </p><p>3 FORM 1A – page 3 APPLICATION FORM FOR DOCTORATE RESEARCH GRANT </p><p>Research Location Name of city or village</p><p>Name of sub-district</p><p>Name of district</p><p>Province Place (eg Laboratorium, green house, hospital) Type of research (circle one) 1. Survey 2. Experimental 3. Laboratorium work 4. Others, specify ...... If this study is part of a bigger research, please mention the name Ethical clearance (circle one) 1. Available, name of institution ……………………… 2. In the process, date submitted & name of institution …………………………………………………….... 3. Not yet processed Field permit (circle one) 1. Available, name of institution ……………………… 2. In the process, date submitted ……………………… 3. Not yet processed Number of planned result dissemination & publication: Seminar/conference</p><p>International journal – obligatory (including name of journal)</p><p>Local journal – optional (including name of journal) Expected output, please elaborate on these aspects: 1. Enhancement of the researcher’s capacity 2. Promotion of scientific research findings recognized by local and international scientific communities 3. Strengthening education and research capacity of the institution 4. Development of scientific community network in the field of nutrition and health 5. Contribute evidence-based recommendations for policy decision 6. Link to current global concern, e.g. Millennium Development Goals (MDGs), Scaling Up Nutrition (SUN), prevention of stunting, prevention of Non- Communicable Diseases (NCDs)</p><p>4</p>