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1. AWARD TYPE
Research Innovation Award
Early Investigator Voucher Awards
Early Investigator Catalyst Awards
2. TITLE OF PROJECT
3. CONTACT PRINCIPAL INVESTIGATOR
3a. NAME (Last, first, middle)
3b. POSITION TITLE
3c. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3d. MAJOR SUBDIVISION
3e. INSTITUTION/ORGANIZATION
3f. TELEPHONE
3g. E-MAIL
4. HUMAN SUBJECTS RESEARCH
No
Yes
5. VERTEBRATE ANIMAL RESEARCH
No
Yes
APPLICABLE IF AT THE UNIVERSITY OF WASHINGTON
APPLICABLE IF NOT AT THE UNIVERSITY OF WASHINGTON
6. CHAIR/DEPARTMENT HEAD
8. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name:
Name:
Title:
Title:
Telephone:
Telephone:
E-Mail:
E-Mail:
7. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
9. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
Name:
Name:
Title:
Title:
Telephone:
Telephone:
E-Mail:
E-Mail:
10. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete and accurate to the best of my
knowledge, and accept the obligation to comply with Public Health Services terms and conditions if a grant is awarded as a result of this application. I am aware
that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil, or administrative penalties.
SIGNATURE OF OFFICIAL NAMED IN 6.
DATE
SIGNATURE OF OFFICIAL NAMED IN 8.
DATE
SIGNATURE OF OFFICIAL NAMED IN 7.
DATE
SIGNATURE OF OFFICIAL NAMED IN 9.
DATE
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