sample preliminary information form (pdf) - amfAR

Research / Grants Administration
120 Wall Street, 13 th Floor
New York, NY 10005
grants@amfar.org
Telephone: +212.806.1752
Mathilde Krim Fellowships in Basic Biomedical Research
Preliminary Information Form and Instructions
If you are considering the submission of a letter of intent (LOI) in response to the current request for proposals for
amfAR’s Mathilde Krim Fellowships in Basic Biomedical Research are required to complete a preliminary information
form and submit it by e-mail to grantapps@amfar.org no later than: 5:00 PM (EDT), July 7, 2009.
Please save your completed preliminary form with the investigator’s last name as the document name (e.g., “smith.doc”).
Submission of preliminary information in no way obligates you to submit an LOI. Details about LOI deadlines and
requirements are detailed in the RFP, which is posted at www.amfar.org/rfp. LOI forms and instructions will be e-
mailed to qualified candidates after receipt of this form. Please contact the grants administration department at
212.806.1752 if you require assistance with this form.
How did you hear about this RFP posting?
1.0 Applicant Organization
A. Institution (full legal name, then any
common abbreviations)*
Street Address
City / State / Country
Please use this field to tell us how you heard about this RFP
University of Anystate
Main Street
Hometown / NY /U.S.A
2.0 Principal Investigator
A. Name: Last/First Emil / Von Berhing
B. Degree (e.g., Ph.D., M.D., Sc.D. – not “Dr.”) Ph.D.
C. Title (e.g., Assistant Professor, Senior Scientist, Post-doctoral
Postdoctoral Fellow
Researcher – not “Dr.”)
D. E-mail evon@anystate.edu
E. Telephone 111-222-3333
F. Department Department of Infectious Diseases
G Mentor: Last/First / Degree / Title
Ivan / Pavlov / Ph.D./ Sr. Research Scientist
H. Date Doctoral Degree Conferred (m/d/yyyy) 6/1/2007
I. On January 1, 2010, how many months of experience
will you have as a post-doc researcher in HIV/AIDS?
30 months
3.0 Proposed Project Details
A. Working Title (Limited to 75 characters and spaces) Biomedical intervention to prevent HIV infection
B. Key Words (Please enter 10 keywords or phrases that
HIV; AIDS; siRNA; Nef; dendritic cells
describe the proposed research)
C. Topic Area Reservoirs Latency/Viral Eradication
D. Research Area Treatment
E. Experts
(please use a semi-colon after each individual’s complete name
and institution affiliation).
Ronald Ross (University College Liverpool); Niels Ryberg
(University of Copenhagen); Robert Koch (University of
Gottingen); Camillo Golgi (University of Pavia)
SEE NEXT PAGE FOR INSTRUCTIONS

INSTRUCTIONS
Preliminary Information Form
Mathilde Krim Fellowships in Basic Biomedical Research
Submission of this form does not obligate the applicant to submit an LOI,
Please read the RFP carefully before completing and submitting this form to ensure that you are a qualified applicant from
an eligible research institution.
Section 1: Please enter:
• The name of the institution that would be the grant recipient 1 and the address of the institution’s main location.
Section 2: Please enter:
• The principal investigator’s name(given name / surname)
• Doctoral-level degrees (e.g., Ph.D., M.D., D.D.S, Sc.D., M.B.B.S – not “Dr.”)
• The title of your position (e.g., Assistant Professor, Senior Scientist, Physician) at the institution that would be
the grant recipient.
• The e-mail address where you can be reached at the present time. You may enter more than one e-mail
address by inserting a semi-colon between addresses.
• The telephone number where you can be reached at the present time.
• The principal investigator’s department at the institution listed above.
• Fellowship applicants are to enter the mentor’s name, degree and title. Mentors are to be experienced,
faculty-level (associate professor or equivalent) HIV/AIDS researchers.
• The month and year that your post-doctorate degree was conferred.
• The number of months you have been a post-doc in HIV/AIDS on January 1, 2010.
See the RFP for information about fellow and mentor qualifications.
Section 3: Bear in mind that minor differences between the information on this form and a submitted LOI are allowed. If
you are contemplating proposals that pose markedly different research questions or are in distinctly different areas of
research, please submit a separate form for each proposal. Should you change your mind about the content of a
proposal, please contact the amfAR’s grants administration department by e-mail to grantapps@amfar.org.
The following information is required from all applicants:
• The title of your project. Please limit the title to no more than 75 characters and spaces.
• Please enter 10 keywords or phrases that describe the proposed research.
• Using the drop down menu, select the topic area that corresponds most closely to the proposal that you plan
to submit. Topics areas are:
1. Immunology
2. Infections or cancers associated with HIV infection
3. Molecular biology
4. Pathogenesis
5. Prevention (including vaccines, microbicides or other biomedical interventions)
6. Reservoirs, latency and viral eradication
7. Therapeutics
8. Virology
• Once again, using the drop down menu please to identify whether your proposal is most closely relevant to
the treatment or prevention of HIV infection.
• Please provide the names and institutional affiliations of five scientists who are not current collaborators and
would be well qualified to review your research proposal.
1 amfAR grants and fellowship grants are awarded to nonprofit institutions (or non-U.S. equivalents) only; they are not awarded to individuals or to forprofit
entities. If requested, documentation of nonprofit status must be provided prior to the activation of a grant.