WTDBT/ECFell/2011

PRELIMINARY APPLICATION FOR AN EARLY CAREER FELLOWSHIP

Q1 Title (Prof, Dr) Forename(s) Surname Current Work Address APPLICANT FELLOWSHIP SUPERVISOR

Host Institution Telephone No. E-mail address Q2

Title of project (not more than 220 characters):

TE
Q4 Q5 Date of birth (dd/mm/yy):

Q3

Proposed start date (dd/mm/yy): PhD Viva date / Expected viva date (mm/yy): Or MD/ MS/ MBBS/MVSc (mm/yy)

PL
Sex: Nationality:
1

AT E

Q 6 CURRICULUM VITAE OF APPLICANT (a) (i) (ii) (ii) (ii) (iii) (b) (i) (ii) (c) Title of current position (If unemployed please give details of last appropriate post): Source of Funding: Location of position: Type of appointment (Contract/Tenure): Start date of appointment (mm/yy)

Do you have a salaried position at your proposed host institution?

Do you have a commitment to a salaried position at your proposed host institution?

Previous posts held: (most recent first) Date from (mm/yy) Date to (mm/yy)

PL
Position and source of funding Degree

AT E
Department University/ Institution Subject University/ Institution
2

TE
(d) Education/training: Date from (mm/yy) Date to (mm/yy) (e) Higher degree:

(i) Are you pursuing a higher degree (PhD, MD or equivalent) or academic course?

(ii) If yes, please specify degree, university and likely date of completion.

( f)

Summary of scientific career to date, including key achievements/awards

( g)

Scientific meetings attended (indicate degree of participation)

TE
(h)

Please outline your reasons for applying to this Fellowship:

PL
3

AT E

(i)

Publications Please list all publications, including original research publications and other scholarly contributions. Publications should be in chronological order with the most recent first. Please give citation in full, including title of paper and all authors. Indicate reviews where appropriate and do not include conference abstracts.

TE

PL
4

AT E

Q7

Research grants / Fellowships from other funding agencies (list the most recent first): If current Nature of Amount Start date End date state time Awarding Title of the Funding awarded (mm/yy) (mm/yy) spent Agency project (Grant/ (hrs/week) Fellowship)

Q8

Is this your first application to the India Alliance?

AT E
Position

YES

NO

If yes, please give details of the previous applications to the India Alliance. (no more than 100 words).

Q9

Has this or a similar application been considered (in the last one YES year), or is currently being considered, by another organisation? If yes, by which organisation?

PL

NO

By what date is a decision expected? If decision is known what was the result?

TE
Q 10

Summary of the research work carried out during PhD (not more than 150 words)

Full Name of Thesis supervisor

Q 11

Outline of proposed research (word limit is 750 words; excluding references)

TE

PL
6

AT E

Q12

Are you planning to continue in the Thesis supervisors laboratory?

YES

NO

If yes, please provide a strong justification for continuing in the same laboratory. Also, please attach a letter from the Thesis supervisor that comments on this decision.*

Name of the External supervisor

Name and Address of the Institute

Purpose of the visit (not more than 50 words)

Q14 Letter of support from proposed Fellowship supervisor * (mandatory) To maintain confidentiality, we encourage the Fellowship supervisor to send their letter directly to the Office, via email to grants@wellcomedbt.org..

TE
Full Name Q15 (a) Institution:

Note: Please note that this letter of support should indicate how Fellowship supervisor would support the research goals and career development of the applicant. Position

Additional Recommendation

Recommendation by Mentor* (mandatory) To maintain confidentiality, we encourage the Mentor to send their letter directly to the Office, via email to grants@wellcomedbt.org. Note: They would typically be an established researcher who has known you for a significant period of time and can provide a detailed letter of recommendation on your abilities. The Mentor cannot be your Fellowship supervisor. Full Name Position

PL

AT E

Work outside host Institute: Q13 This section must be completed by applicants proposing to work in another Institution in India or abroad for part of their Fellowship. (Research work can be planned for up to 24 months outside the host institution)

Q 16

Where did you learn of this scheme? (Please indicate most appropriate) Colleague Personal contact India Alliance Website Facebook / Linkedin Conference/Exhibition/Workshop Newspaper/ Magazine Google advert Others (specify)

Important things to remember at the time of submitting a preliminary application: 1. 2. 3. 4. 5. Application should be sent online to info@wellcomedbt.org. Hard copies are discouraged. Deadline for submitting the preliminary application is 17 August 2011. The letters requested in the application should reach the Office by 17 August 2011. Late or incomplete applications would be automatically disqualified from the competition. A decision on your application would be conveyed by the Office within 4-6 weeks.

Contribute your opinion; please participate in our survey at http://wellcomedbt.org/online_survey.html

TE

PL
8

AT E

TE M PL AT E