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					                                          FRANCE PARKINSON
                                          Reconnue d’utilité publique (décret du 17 juin 1988)
                                         4 avenue du Colonel Bonnet – 75016 PARIS
                    Tél. 01 45 20 22 20 – Fax : 01 40 50 16 44 – mail : scientific@franceparkinson.fr



                                            APPLICATION FORM
                                         GRAND APPEL D’OFFRE 2012
               (must include several research teams with at least one French coordinator team)

                                Soumission du dossier au plus tard le 15 mars 2012

Team designation (team 1, project coordinator): …………………………………………………….
Address: ………………………………………………………………………………………………..
Tel: …………….. .. ……………………. Fax: ………………………………………………………..
Email address: ………………………………… @................................................................................
Name & title of the project coordinator: ……………………………………………………………….
………………………………………………………………………………………………………….
Main collaborators involved in the project: ……………………………………………………………
………………………………………………………………………………………………………….
Research team main interest: ..................................................................................................................
Research team status: ………………………………………………………………………………….
Main origin of team resources: ………………………………………………………………………..


Team designation (team 2) *: …………………………………………………………………………
Address: ……………………………………………………………………………………………….
Tel: ........................................................... Fax: ……………………………………………………...
Email address: ………………………………… @..............................................................................
Name & title of Research team head and main collaborators: ………………………………………..
…………………………………………………………………………………………………………
…………………………………………………………………………………………………………
Research team main interest: …………………………………………………………………………
Research team status: …………………………………………………………………………………
Main origin of team resources: ……………………………………………………………………….
* reproduce as many boxes as necessary (each one designating a different Research team)




             Please include for each Research team a short list of main original articles published
                                                        during the past 5 years.




                                                                        1
                                          FRANCE PARKINSON


Project Research title: ………………………………………………………………………………
…………………………………………………………………………………………………………..
Total amount expected from France Parkinson: ………………………………………………
Other grants obtained or expected for the project (whom from & what amount): ……………………
....................................................................................................................................... …………..…….
Planned timeline of project: …………………………………………………………………….
Note: If you wish to use the amount assigned for the functioning (please supply details) or for the
equipment (please supply the estimate).

Your Research project description must be completed taking into account the following study
rationale: HOW WILL THIS PROJECT CONTRIBUTE IN IMPROVING OUR KNOWLEDGE IN
PARKINSON’S DISEASE?
Do not exceed 2/3 pages, summary & references included:

     a. Project’s summary
     b. Project’s objective, rationale & methods
     c. Nature of the means (human, local, material, specific techniques) available or necessary
        for the realisation of the project
     d. Task details or responsibilities for each Research team
     e. Bibliographical references

France Parkinson asks for the following commitments:

1. to respect the specifications of the present call for tender,
2. to mention the support of France Parkinson in any publication related to the Research project and
   to send the publication to our non profit organisation,
3. to hand back a scientific report on the project results at the latest 6 months after the end of the
   planned timeline for the project.

Date : ………………….

Name of the project coordinator (team 1): ………………………………………………………..

                                         Signature:
Name of the main applicant (team 2): ………………………………………………………………

                                         Signature:
Name of the main applicant (team 3): ……………………………………………………………..

                                                                      Signature:




Quel sera l’organisme chargé de la gestion de votre budget : …………………………………………………
Préciser le nom du responsable administratif de cet organisme : ……………………………………………..
Tél. : …………………………….. et adresse mail : ………………………………….@………………………..




                                                                        2
FRANCE PARKINSON




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