Building a collaborationApplication form

2016

This application form should be read in conjunction with: Call for Applications (individual document for each topic) Application Overview

APPLICATION FORM

This form has been prepared in MS Word, using a table format that will expand as content is inserted. Please do not delete or re-format any of the content such as questions or instructions.

Please comply with the word limits. Applications not complying with the word limits may not be considered. Text should be 12 point and the font Calibri.

Please note that, if you do not complete all relevant sections of this application or fail to supply any necessary supporting documentation it may not be possible for the Lowitja Institute to process your application.

Administering institution (Must be a Lowitja Institute CRC Participant Organisation)

1. Name of person completing this funding application

Title

Name

Position/ Organisation

Email

Telephone

2. Application code

INSERT THE CODE HERE

3. Title

INSERT THE DATE HERE

4. Application closing date (as per Call for Application)

INSERT THE DATE HERE

5. Proposed project start date

INSERT THE DATE HERE

6. Proposed project completion date

The Lowitja Institute Application Form 20162

INSERT THE DATE HERE

7. Approach to building a collaboration – (maximum 700 words)

Provide a brief overview of the proposed approach to developing effective collaboration with relevant industry partners:

INSERT YOUR TEXT HERE

8. Process of development of research proposal suitable for submission to a competitive funding scheme – (maximum 700 words)

Outline your proposed process for the development of a coherent, evidence-based application for funding for an intervention trial.

INSERT YOUR TEXT HERE

The named Project Leader must have a substantial appointment with the Administering Institution.

9. A brief statement of the team capability.

Please outline the experience and expertise of each member of the proposed project team. Please indicate Aboriginal and Torres Strait Islander personnel.

(a) Project Leader (maximum 500 words including top 5 relevant publications)

INSERT YOUR TEXT HERE

(b)Project personnel (maximum 250 words including top 5 relevant publications)

Please include any additional positions you would recruit to the project team. INSERT YOUR TEXT HERE

10. Budget

Applicants must provide a detailed budget of the expected cost for their application to build a collaboration using the budget tool available at http://www.lowitja.org.au/sites/default/files/docs/budget-template.xlsx

The Lowitja Institute Application Form 20163

11. Is there any background IP to be brought to the Research Project? Background IP is IP that has been developed before the project commenced which you will bring to the project. Any background IP should be identified.

(Maximum 300 words)

INSERT YOUR TEXT HERE

12. Administering Institution details

Insert institution name and contact details

13. Please indicate if this project has been funded or is likely to be funded elsewhere, or is linked to a project funded elsewhere.

Yes / No

If yes, please specify

Insert name of project and of funding body

14. Partner Details

If applicable, insert the names and contact details of all partner organisations involved in this project.

Upload any documents in support of the application. Note all support documents should be consolidated into a single Word or PDF file (i.e. only one attachment is allowed)

15. Evidence of support, if any, has been uploaded as one Word or PDF document.

Yes / NoPlease upload any documents to support this application at http://www.lowitja.org.au/research-funding-application

Applicant declarationPlease note that this declaration must be made again at http://www.lowitja.org.au/collaboration-application when you upload and submit this application.

I declare that the information supplied in this application is true and correct and that all required supporting documents have been supplied. I have original copies of all submitted documents and understand that the Lowitja Institute may request sighting the original documents for the purpose of verification. I acknowledge that all documents submitted will become the property of the Institute and will not be returned to me.

The Lowitja Institute Application Form 20164

Yes / No

I understand that the information collected in this application form will enable the Lowitja Institute to assess my application and, if my application is successful, create a legally binding Research Activity Funding Agreement. I also understand that if I do not complete all relevant sections of this application or fail to supply necessary supporting documentation it may not be possible for the Lowitja Institute to process my application.

Yes / No

I understand that it is a serious offence under the Criminal Code of the Australian Commonwealth to give misleading or false information and I acknowledge that the Lowitja Institute reserves the right to reverse any decision made about my application for research funding if it is found that I have provided misleading or false information.

Yes / No

Name of authorised person making this application and declaration(Must be representative of the Administering Institution)

Position

Date

Please note you will receive an auto-generated email following your submission. If you do not receive this in 24 hours, please contact Dr Jill Guthrie, Director, Research and Knowledge Translation phone 03 8341 5508.

---ends---

The Lowitja Institute Application Form 20165