2023 ASNC/Pfizer Young Investigator in Cardiac Amyloidosis Research Fellowship Award Application Survey

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* 1. Please provide your name, degrees, job title, email and phone.

First Name

Last Name

Degree(s)

Job Title

Email Address

Phone

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* 2. Please provide your institution's address.

Institution *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

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* 3. Are you currently an ASNC Member?

Yes

No (ASNC membership is required in order to apply.)

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* 4. List your current and past ASNC participation.

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* 5. Upload your NIH Biosketch.

PDF, DOC, DOCX file types only.

Choose File

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* 6. Do you currently have other grant support or funding?

Yes

If yes, please describe.

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* 7. Enter the title of your research project.

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* 8. Enter the start date of the proposed period of support.

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* 9. Enter the end date of the proposed period of support.

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* 10. Will you be using human subjects for research?

Yes

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* 11. Will you be using vertebrate animal subjects for research?

Yes

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* 12. Provide a summary, in no more than 500 words, of the proposed research and specific aims of the project.

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* 13. Please provide your mentor's information.

First Name

Last Name

Degree(s)

Job Title

Institution

Email Address

Phone

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* 14. Is your mentor an ASNC Member?

Yes

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* 15. What is your mentor's past and current ASNC participation?

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* 16. Please upload your Statement of Mentor.

PDF, DOC, DOCX file types only.

Choose File

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* 17. Enter key personnel who will contribute to the project (complete the fields for each person).

1. First, Last Name

Institution

Role on project

2. First, Last Name

Institution

Role on project

3. First, Last Name

Institution

Role on project

4. First, Last Name

Institution

Role on project

5. First, Last Name

Institution

Role on project

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* 18. Please upload the NIH Biosketch forms for each of the key personnel (combine into one file).

If assistance is needed, email info@asnc.org.

PDF, DOC, DOCX file types only.

Choose File

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* 19. Enter the estimated personnel costs (enter Name, Role on Project and Dollar Amount Requested).

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* 20. Enter estimated equipment costs (enter Item Description and Cost).

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* 21. Enter additional expenses (enter $0 if not applicable).

Estimated supply costs

Estimated consultant costs

Patient care costs (inpatient)

Patient care costs (outpatient)

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* 22. Please enter your total estimated costs for the project.

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* 23. List the facilities that will be utilized for the duration of the proposed project (enter N/A if not applicable).

Laboratory

Clinical

Animal

Computer

Office

Other

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* 24. List major equipment already available to you for this project.

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* 25. Upload the project details.

No more than 5 pages in a single file.

PDF, DOC, DOCX file types only.

Choose File

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* 26. Upload your personal statement.

No more than 2 pages in a single file.

PDF, DOC, DOCX file types only.

Choose File

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* 27. Please upload 3 letters of reference.

Combine the letters into a single file. Each letter can be no more than 2 pages.

PDF, DOC, DOCX file types only.

Choose File

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* 28. Other expenses (enter Item Description and Cost).

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* 29. Enter Certifying Official information.

First Name

Last Name

Title

Phone

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* 30. Enter your institution grant official's certification and acceptance.

I certify that the submitted application materials are complete and accurate to the best of my knowledge.

2023 ASNC/Pfizer Young Investigator in Cardiac Amyloidosis Research Fellowship Award Application

Applications may also be sent to: info@asnc.org

Question Title

* 1. Please provide your name, degrees, job title, email and phone.

Question Title

* 2. Please provide your institution's address.

Question Title

* 3. Are you currently an ASNC Member?

Question Title

* 4. List your current and past ASNC participation.

Question Title

* 5. Upload your NIH Biosketch.

Question Title

* 6. Do you currently have other grant support or funding?

Question Title

* 7. Enter the title of your research project.

Question Title

* 8. Enter the start date of the proposed period of support.

Question Title

* 9. Enter the end date of the proposed period of support.

Question Title

* 10. Will you be using human subjects for research?

Question Title

* 11. Will you be using vertebrate animal subjects for research?

Question Title

* 12. Provide a summary, in no more than 500 words, of the proposed research and specific aims of the project.

Question Title

* 13. Please provide your mentor's information.

Question Title

* 14. Is your mentor an ASNC Member?

Question Title

* 15. What is your mentor's past and current ASNC participation?

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* 16. Please upload your Statement of Mentor.

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* 17. Enter key personnel who will contribute to the project (complete the fields for each person).

Question Title

* 18. Please upload the NIH Biosketch forms for each of the key personnel (combine into one file).

Question Title

* 19. Enter the estimated personnel costs (enter Name, Role on Project and Dollar Amount Requested).

Question Title

* 20. Enter estimated equipment costs (enter Item Description and Cost).

Question Title

* 21. Enter additional expenses (enter $0 if not applicable).

Question Title

* 22. Please enter your total estimated costs for the project.

Question Title

* 23. List the facilities that will be utilized for the duration of the proposed project (enter N/A if not applicable).

Question Title

* 24. List major equipment already available to you for this project.

Question Title

* 25. Upload the project details.

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* 26. Upload your personal statement.

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* 27. Please upload 3 letters of reference.

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* 28. Other expenses (enter Item Description and Cost).

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* 29. Enter Certifying Official information.

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* 30. Enter your institution grant official's certification and acceptance.