RESEARCH GRANT PROPOSAL 2016

Letter of INTENT

The proposed project is a candidate for (tick one box only)

the"REHABILITATION" call for projects

the "GENERAL"call for projects

PROJECT LEADER (=THE APPLICANT)

SURNAME:

FIRST NAME:

TITLE OF PROJECT (200 characters max.):

E mail address for follow-up:

Applicant

Surname:	First Name	:

Maiden Name:

Date of birth:	Citizenship:

Address:

Phone #:	Mobile phone:

E-mail address:

Qualification (Medical or University degree)

Applicant’s resume (CV less than 3,000 characters)

In case of application for a student: CV of the student (half page maximum) and School Name (Address, Tel, E-mail)

Lab, department, or branch where the research will be conducted

Name of Lab, department, branch:

Research Centre, Hospital, University…:

Address:

Zip code:

City:

Country:

Telephone #:	Fax #:

E-mail address:

Director:

Surname:	First name:

E-mail address:

Telephone #:	Fax #:

Main studied field (200 characters max.)

Laboratory Publications (3 major ones in the last 5 years)

Budget Chart

Total budget of the project including the amount requested from La Fondation Motrice (in thousands €) : ___________________

Amount requested from La Fondation Motrice (in thousands €, VAT included) Please specify below

Nature	Amount (VAT included)
Operational expenses
Student (1)
Post-doctoral student (2)
Temporary staff
Management expenses
Total

(1)Master’s (2nd year) and PhD (1st, 2nd, 3rd year)

(2) Post-doctoral students (1st, 2nd, 3rd year)

Co-Financing

YES	NO

Co-financing received (name each sponsoring entity, date of agreement, amount received, proof of no-exclusivity clauses)

Co-financing requested (name each sponsoring entity, provisional date of agreement, amount requested)

Possible co-financing (name each sponsoring entity, possible date of agreement and amount)

Fund manager unit (name and address)

Scientific summary of the project

In English or French (2 pages maximum, arial 11, single space) divided into the following sequence of headed sections

Title,

Background,

Primary hypothesis,

Primary and secondary objectives,

Methodology (experimental design, inclusion criteria…),

Feasibility,

Evaluation criteria,

Statistical analysis,

Ethics (Ethic committee if applicable), Sponsor of the study (if applicable),

Potential collaborations,

Foreseeable results and impact on concerned people (prevention, rehabilitation changes, drug therapy, etc..).

I hereby certify that all information provided herein is true

In :

Date :

Applicant’s signature

Letters of Intent must be sent before

June 20th 2015 (5 pm, Paris time) by email one file in PDF or Word format (no scan) to: fondationmotrice@gmail.com

and

June 25th 2015 on paper in 1 counterpart to:

LA FONDATION MOTRICE

Appel à projets 2016

67 rue Vergniaud

75013 PARIS, France