Invited final application for an amr centre project (стр. 1 )

INVITED FINAL APPLICATION FOR

AN AMR CENTRE PROJECT

The completed form and associated documents must be submitted electronically and received at the AMR Centre before 5pm GMT 9 September 2016. The form and documents should be sent to Ian Grundy (Ian. *****@***com).

If you have a question about the Application procedure or the completion of this form, or are experiencing technical difficulties with the Application form please consult with your AMR Centre business contact.

Index to sections of the form:

Undertakings......................................................................................................................................................................... 2

Contact details:..................................................................................................................................................................... 4

Project Details:..................................................................................................................................................................... 7

Curricula Vitae:.................................................................................................................................................................. 13

APPLICATION FOR A LATE STAGE

SEEDING DRUG DISCOVERY AWARD

AMR Centre DATA PROTECTION STATEMENT 1.  This statement is a “fair processing notice” under the Data Protection Act 1998 (the “Act”) and sets out what the AMR Centre will do with the information that it collects from you during the grant/award application process and throughout the life of the grant/award (including all information relating to the grant/award application and, as applicable, any subsequent grant/award made). 2.  Information (including “personal data” as defined under the Act) that you supply to the AMR Centre, including in any application and progress or update report, may be used by the AMR Centre to process applications and administer grants/awards, for the purposes of audit and evaluation and to monitor the fairness of and trends in application decisions. Your information may be disclosed for these purposes only to individuals and organisations connected with the AMR Centre, including funding partners, external peer reviewers and external committee members. Your information may also be shared with selected third parties for the purpose of independent audit, evaluation and assessment of activities funded by the grant/award and their outputs and outcomes. Some of these third parties may be based outside the European Economic Area. All personal data will be stored and used by or on behalf of the AMR Centre in accordance with the Act. 3.  The AMR Centre may anonymize your personal data and use it for research and statistical purposes. 4.  The AMR Centre may contact you about its activities and events, or to help inform or evaluate these activities and events, AMR Centre application processes and policy work. 5.  The AMR Centre may amend this Statement from time to time.

UNDERTAKINGS

1.	I confirm that I (and all those providing personal information in the application) have read and understood the AMR Centre Data Protection statement above.
2.	To the best of my knowledge, the information provided in this application is accurate and complete and I agree to inform the AMR Centre of any material changes to this information during the period of the grant/award.

Signature of Principal Applicant		Date:
Signature of Coapplicant (1)		Date:
Signature of Coapplicant (2)		Date:
Signature of Coapplicant (3)		Date:
		Date:

Continued overleaf

Contact details:

Principal Applicant
Name			Telephone numbers:
Contact address		Day
Mobile
Fax.
e-mail

Please duplicate Coapplicant section as required

Coapplicant (1)
Name			Telephone numbers:
Contact address		Day
Mobile
Fax.
e-mail

Coapplicant (2)
Name			Telephone numbers:
contact address		Day
Mobile
Fax.
e-mail

Company details:

If a company please provide the following:

	Company number:
	Date and place of incorporation:
	Registered office:
	Number of employees:

INVITED FINAL APPLICATION FOR

AN AMR CENTRE PROJECT

Q1 Applicants	Principal Applicant	Coapplicant (1)
Surname
Forenames
Title (Dr etc.)

	Coapplicant (2)	Coapplicant (3)
Surname
Forenames
Title (Dr etc.)

Q2	Company name and address or department name and address at administering institution:

Q3	Title of project: (no more than 220 characters, including spaces)

Q4	SUMMARY OF PROPOSED RESEARCH INCLUDING KEY GOALS
(a)	For scientifically qualified assessors: (no more than 200 words)

Q5	Total Funding Estimate for Project
Q6	Estimated duration of project:(state in months)

Q7

Proposed start date: (dd/mm/yy)

Q8	RELATED APPLICATIONS
(a)	Is this or a related application currently being submitted elsewhere?	YES		NO
	If yes, to which organisation?
	By what date is a decision expected? (dd/mm/yy)
(b)	Has this, or a similar, application been submitted elsewhere over the past year?	YES		NO
	If yes, to which organisation?
	What was the result?
(c)	Is this application a resubmission?	YES		NO
	If yes, when was it originally considered?
	Please give the AMR Centre’s reference number:
	Briefly state how this application differs from the original (no more than 250 words)

Project Details:

Q9	Disease Background: Please provide brief details on the following; (no more than Ѕ page per section)
(a)	Defined disease indication and prevalence

(b)	Summarise the Treatment Patient Population for this disease indication (150 words max.)

(c)	Differentiation of the proposed approach over other mechanisms (e. g. greater efficacy, improved safety, increased patient convenience etc)

(d)	Is the proposed new compound to be a first, second or third-line therapy?
(e)	What co-medications is the therapy likely to be used with or to displace?
(f)	How is the target patient population identified and selected for treatment?

(g)	Please provide up to five relevant references to the background of this proposal

For Questions 10 and 11 the applicant(s) should use the Tables in Appendix 1 to present the data they have generated to date on their project, in conjunction with the questions.