Fellowship Form

Name of applicant *

CONTACT DETAILS

Contact details

Email *

Address *

Phone *

QUALIFICATIONS

Qualifications

Attach curriculum vitae *

Current position *

PROPOSED SUPERVISOR

Proposed supervisor

Name *

Email *

Address *

Phone *

MSBase centre code *

PROPOSED HOST INSTITUTION

Proposed host Institution:

Name of person authorised to approve Fellowship *

Email *

Address *

Phone *

PROPOSED PROJECT TO BE ACHIEVED DURING FELLOWSHIP

Proposed project to be achieved during Fellowship including:

Aim, objectives, brief literature review, design and methodology, feasibility, expected outcome
Timelines
Training Plan as developed with proposed supervisor
Proposed travel and or conference attendance
Proposed authorship for publication/s giving consideration to the MSBase Foundation Authorship and Publication Guidelines for MSBase data.

Proposed project *

Personal Statement. What do you hope to personally gain from the Fellowship including plans for your future career: *

How will the MSBase Foundation, Registry members or MS patients benefit from the proposed project, and how will you evaluate the success of your Fellowship? *

BUDGET

Budget

Provide a budget that includes a plan for how it is expected the funds will be used including projected stipend, travel, meeting attendance, training and how any shortfall will be covered. *

LETTER OF SUPPORT

Letter of support

A letter of support must be attached that has been prepared by your proposed supervisor who must be a MSBase member, and co-signed by the relevant person within the not-for-profit host organisation who has the authority to approve the fellowship position. The letter of support should indicate the length of time that the Fellow can be hosted and the contribution made by the host to the Fellowship including top up funding.

Attach letter of support *

AGREEMENT

Agreement to abide by all MSBase Foundation rules, policies and procedures:

If you are successful, you must be willing to become familiar with all relevant MSBase Foundation rules, policies and procedures and abide by these during the Fellowship. E.g. MSBase Foundation Authorship and Publication Guidelines for MSBase data; Process for accessing the global dataset; Privacy and Confidentiality.

If you are successful, you must be willing to become familiar with all relevant MSBase Foundation rules, policies and procedures and abide by these during the Fellowship. E.g. MSBase Foundation Authorship and Publication Guidelines for MSBase data; Process for accessing the global dataset; Privacy and Confidentiality. *

I agree to the above statement

Your full name *

Date *

Fellowship Form

Have questions?

Contact details

Qualifications

Proposed supervisor

Proposed host Institution:

Proposed project to be achieved during Fellowship including:

Budget

Letter of support

Agreement to abide by all MSBase Foundation rules, policies and procedures: