Paradigm Spine Grant Application (Page 3 of 7) in pdf

1. PRINCIPAL REQUESTOR INFORMATION

2a. NAME:

2b. DEGREES:

( L a s t , F i r s t , M i d d l e )

2c. POSITION TITLE:

2d. BUSINESS ADDRESS

(Street, City, State, Zip)

2e. DEPARTMENT, SERVICE, LABORATORY OR EQUIVALENT

2f. TELEPHONE AND FAX

2g. EMAIL ADDRESS (required)

(Area code, number, extension)

Tel.:

Fax:

3. HUMAN SUBJECTS:

YES

4. VERTEBRATE ANIMALS:

YES

3a. If “YES”, Exemption #:

4a. If, “YES”, IACUC

IRB Approval Date:

4b. Animal Welfare Assurance #:

Full IRB

Expedited Review

. DATES OF PROPOSED PERIOD OF SUPPORT:

COSTS REQUESTED FOR EACH YEAR:

TOTAL COSTS REQUESTED

YEAR 1

YEAR 2

. APPLICANT ORGANIZATION NAME:

. ADDRESS:

. FEDERAL ID #:

9. DEPARTMENT CHAIR

10. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION

(Administrative Official to be notified if Grant is made)

Name:

Business Address:

Title:

Business Address:

City, State, Zip:

Phone:

City, State, Zip:

Fax:

Phone:

E-mail (required):

Fax

Signature:

E-mail (required)

Date:

11. PRINCIPAL INVESTIGATOR ASSURANCE:

SIGNATURE OF PI NAMED IN 2a:

Date:

I certify that the statements herein are true, complete and accurate to the

(In ink. “Per” signature not acceptable.)

best of my knowledge. I am aware that any false, fictitious, or fraudulent

statements or claims may subject me to administrative penalties. I agree to

accept responsibility for the scientific conduct of the project and to provide

the required progress reports if a grant is awarded as a result of this

application

12. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE:

SIGNATURE OF OFFICIAL NAMED IN 10:

Date:

I certify that the statements herein are true, complete and accurate to the

(In ink. “Per” signature not acceptable.)

best of my knowledge, and accept the obligation to comply with OREF 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

administrative penalties.

Paradigm Spine Grant Application Page 3

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