Face Page
Project Title:
Application Type: Summer Undergraduate Experience
NYSTEM Application #:
Principal Investigator:
Last Name, First Name, Middle Initial, Degree(s)
,
,
,
Co-Principal Investigator:
Last Name, First Name, Middle Initial, Degree(s)
,
,
,
Institution:
Institution:
Department:
Department:
Mailing Address (Street, MS, P.O. Box, City, State, Zip):
Mailing Address(Street, MS, P.O. Box, City, State, Zip):
Street 1
Street 2
City
Street 1
Street 2
City
State
Zip
State
Early Stage Inv.:
Zip
Phone:
Fax:
Phone:
Fax:
E-mail:
E-mail:
Type of Organization:
Federal Employer ID # (9 digits):
DUNS Number:
Charities Registration Number (or “Exempt category”):
F&A Costs: Status of DHHS Agreement:
please explain and give a date here:
Project
Year One
Start/End:
Grand Total Costs:
New York State Applicant Organization:
Grand Total Costs:
Research Performing Sites:
Mailing Address (Street, MS, PO Box, City, State, Zip):
Street 1
Street 2
City
State
Zip
Contracts and Grants Official:(Last Name, First Name)
Last Name
, First Name
Official Signing for the Organization (Name and Title):
Last Name
First Name
Title
Mailing Address (Street, PO Box, MS, City, State, Zip): Organization Name and Mailing Address:
(Street, MS, PO Box, City, State, Zip)
Street 1
Street 1
Street 2
Street 2
City
State
Zip
City
State
Zip
Phone:
Fax:
Phone:
Fax:
E-mail:
E-mail:
Address where reimbursement should be sent if contract is awarded (Street, MS,PO Box, City, NY, Zip):
Street 1
Street 2
City
State
Zip
CERTIFICATION AND ASSURANCE: I certify that the statements herein are true and complete to the best of
my knowledge. I agree to accept responsibility for the scientific conduct and integrity of the research, and to
provide the required progress reports if a contract is awarded as a result of this application.
SIGNATURES OF PRINCIPAL INVESTIGATOR and CO-PI (“Per” not allowed):
X
DATE:
X
DATE:
ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true and
complete to the best of my knowledge, and I accept the obligation to comply with the Empire State Stem Cell
Board’s terms and conditions if a contract is awarded as a result of this application.
SIGNATURE OF THE OFFICAL SIGNING FOR THE APPLICANT ORGANIZATION (“Per” not allowed) :
X
DATE:
Form 1
Submit Forms 1-3 together in two formats: one signed PDF file and one Word document file.
1
Staff, Collaborators, Consultants and Contributors
List the name, title and institutional affiliation of all staff, collaborators, consultants and contributors (both
paid and unpaid). This list is used for identifying potential members of the Independent Scientific Merit Peer
Review Panel.
Last Name
First Name
Title
Institutional Affiliation
Form 2
Submit Forms 1-3 together in two formats: one signed PDF file and one Word document file.
2
Role in Project
Lay Abstract
Provide a 300 word summary of the application, in non-technical terms. This information will be
excerpted and edited for use in various public documents. Specifically, provide an
Introduction/Background, a Summary of Goals and Objectives, and describe the Innovative
Elements of the Project.
Form 3
Not to exceed 300 words.
Submit Forms 1-3 together in two formats: one signed PDF file and one Word document file.
3