AMERICAN SPECIALIST INFORMATION - COBASE Grants Program Application Form 2002-2003

AMERICAN SPECIALIST INFORMATION - COBASE Grants Program Application Form 2002-2003

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American Specialist Information

I. Deadline Choice (please check one)

A.

Project Development and Initiation 02PDI1 – January 4, 2002 deadline

Project Development and Initiation 02PDI2 – April 15, 2002 deadline

Project Development and Initiation 02PDI3 – August 27, 2002 deadline

B.  You may apply to host and/or travel on the same grant.  Please indicate your plans below.

I will host:                       (foreign specialist name) from                     (country)

I will travel to:                        (country)

II. Expected Dates of Visit(s) (Note: The NRC will not reimburse for expenses incurred prior to the date on which the award terms of agreement are signed by the recipient. Please do not initiate any visit before receiving and signing award terms.) You may request one or two visits, with combined duration no more than 8 weeks.

1. Start date:                                Completion date:       

2. Start date:                                Completion date:

American Specialist Information

1. Last name:                     First name:                  MI:

2. Sex:   M    F                 3. Date of birth:

4. Highest degree earned:                    Year awarded:             Field:        

5. Office phone:                    Fax:                     E-mail:      

6. Permanent professional affiliation and mailing address: 

7. Current mailing address (if different from above):   

8: Citizenship status:  U.S. citizen    U.S. permanent resident    Other:           (country)

9. How did you learn about the COBASE grants program?

10. Have you previously participated in NRC grants programs?   Yes    No

11. Do you hold a current NSF grant?   Yes    No

If yes, please list grant number below. Before applying to COBASE, current NSF grantees should contact NSF’s Eastern Europe program (703-292-8703) regarding a possible supplement. If such a supplement is not available, please indicate the reason below, or on a separate sheet.

12. General scientific field of proposed activity (i.e., biology, chemistry, physics, etc. Also, if you are applying under one of the special topical focus areas, please indicate it here):

13. Subfield of proposed activity:

14. Briefly describe your proposed activity in the space below. This will be used to identify appropriate peer/panel reviewers. PLEASE DO NOT EXCEED 5 LINES.

15. Please provide the names, addresses and telephone numbers of individuals (in the United States or Canada) competent in your field of research who might be qualified to serve as scientific reviewers of this application. Please do not list individuals at your institution, research collaborators, or persons who would otherwise have a conflict of interest.

OMISSION OF ANY OF THE REQUESTED SUPPLEMENTAL MATERIALS, AS WELL AS THE REQUEST NUMBER OF COPIES, WILL JEOPARDIZE THE SUCCESS OF THE APPLICATION.

Please review this application form to be certain that all information is complete.

Signature:

Date: 

FOREIGN SPECIALIST INFORMATION - COBASE Grants Program Application Form 2002-2003

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Foreign Specialist Information

(to be completed by U.S. applicant)

Note to U.S. applicants: These questions refer to your foreign colleague. You must submit this form as part of your COBASE application regardless of whether you propose to host, travel, or both.

1. Last name:   First name:   MI:

2. Sex:   M    F                 3. Date of birth:

4. Country of citizenship:

5. Highest degree earned:    Year awarded:   Field:

6. Permanent professional affiliation:

7. Title/Position:

8. Has your colleague previously participated in NRC grants programs?   Yes    No

9. Please indicate your colleague’s English language proficiency:

Reading only

Fluency adequate for all daily and professional needs

Basic conversation

Bilingual

10. Please list your colleague’s previous international travel/work experience.

STATEMENT OF RESPONSIBILITIES - COBASE Grants Program Application Form 2002-2003

Statement of Responsibilities

(to be completed by U.S. applicant)

1.  I understand that all air travel charged to this grant must be by U.S. air carrier.  If such service is not available on any leg of my or my foreign colleague’s trip(s), I will contact the NRC staff officer for advance authorization (Kelly Robbins at krobbins@nas.edu or TEL 202-334-3656).