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Application Form - Funding Program of the Medical and Dental Staff University Mission Fund

Project title *

Principal investigator

(Physician at the Dr. Georges-L.-Dumont University Hospital Centre)

First and last name *

Institutional affiliation *

Does this person currently hold a faculty appointment at the CFMNB (e.g., clinical professor)? *

Yes

No

Mailing address *

Email address *

Telephone number *

Other members of the research team

Add another member to the research team

First and last name *

Role in the team *

Institutional affiliation *

Mailing address *

Email address *

Telephone number *

Add another member to the research team

First and last name *

Role in the team *

Institutional affiliation *

Mailing address *

Email address *

Telephone number *

Summary of the project in plain language (maximum 200 words): *

Principal investigator’s curriculum vitae (free format) *

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Other members’ curriculum vitae (free format) *

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Project description (two pages maximum, Times New Roman, 12-point font, standard margins) *

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Description of team members’ roles. Please describe the complementarities among team members and the nature of the collaboration (maximum two pages, no specific format required). *

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Budget: Summary table of project implementation expenses (maximum $10,000) *

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Budget justification (one page maximum) *

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Work plan and project timeline *

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Phone