APPLICATION FORM FA-2015
THE GRASS FELLOWSHIP PROGRAM AT MBL
* indicates that item is optional or does not apply to all applicants
Changing this document to alter the meaning or intent of the forms will invalidate your application. Most
fields will expand to accommodate more text, but please stay within the word limits.
A. APPLICANT INFORMATION
Full name (Last, First, Middle*) Last Name, First Name.
Title of proposed project
Proposal Title
Abstract of proposed project (please no more than 250 words). Insert here:
Abstract.
Applicant’s Institution
Click here to enter text.
Dept./Program
Click here to enter text.
Present position (e.g., Ph.D. student at UCLA) Click here to enter text.
*Current research supervisor Click here to enter text.
Education: List all degrees, with the date received or expected.
Date
Degree & field (e.g., B.S., Biology)
Institution
year.
year.
year.
Degree.
Degree.
Degree.
Institution.
Institution.
Institution.
Animal information: Species or common name(s):Animal Species.
i.
Do you have prior experience working with this/these species?
ii.
Do the experiments involve survival surgery?
iii.
Prior MBL experience: Have you spent time at MBL previously?
*If yes, please explain: Previous MBL.
yes ☐
yes ☐
no ☐
no ☐
yes ☐
no ☐
Citizenship
i.
What citizenship do you hold? Citizenship.
ii.
*If applicable, what type of US visa do you hold? US Visa Type.
iii.
*Do you agree to apply for a J-1 visa if required?
yes ☐ no ☐
iv.
*If you hold an H1B, F1, E3 or TN visa do you agree to also submit form GF-H1B?
yes ☐ no ☐ (this form is available on www.grassfoundation.org)
Letters of Reference: List the names of the three (or four, if working outside the Grass Lab; see
Instructions) individuals submitting letters on your behalf.
Name
Institution
Last Name, First Name.
e-mail
1
1.Name.
2. Name.
3. Name.
*4. Name.
Institution.
Institution.
Institution.
Institution.
Email.
Email.
Email.
Email.
B. CONTACT INFORMATION
Institutional Address
Street Text.
Home Address
Street Text.
City Text.
City Text.
State Text.
State Text.
Zip/Postal Text.
Zip/Postal Text.
Country Text.
Country Text.
Phone Text.
Phone Text.
E-mail Text.
E-mail* Text.
(only one e-mail address is required)
Preferred Mailing Address:
Preferred E-mail Address:
Institution ☐ Home ☐
Institution ☐ Home ☐
C. CURRICULUM VITAE. See Instructions. Please append this to the end of Form FA-2015.
D. RESEARCH PROPOSAL. See Instructions. Please append this to the end of Form FA-2015.
E. DATES AND RESEARCH LOCATION
Dates: The 2015 program runs from 25 May to 29 August, inclusive. Any proposed deviation from these
dates, including late arrival date, early departure date or an absence during the program, must be
disclosed and justified here:
Justification different tenure.
Space: Check as appropriate:
☐I will need space in the shared Grass Laboratory.
☐I have made definite plans to work in the laboratory of Name of MBL Person.
at MBL, who will submit a letter of reference (see Section A).
☐My plans for research space are not yet finalized.
F. BUDGET
1. RESEARCH EXPENSES
a. Laboratory Equipment. See Instructions (if more space for equipment is needed please attach a
separate table with the same fields).
Item
Potential manufacturer and
Source (home If brought from
model number
or loaner via
home, cost of
Grass)
round-trip
please give alternatives if
shipping
possible.
Last Name, First Name.
2
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Description.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
Manufacturer.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
source.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Ship$.
Total estimated cost of round-trip transport or shipping from home institution: $ Total Shipping.
*Other transport/shipping costs if applicable (e.g., U-Haul rental, etc.) $ Other Transport.
b. Special Facilities/Equipment.
I will need the following special facilities or equipment (check as appropriate).
☐ None
☐ Darkened space for experiments
☐ Hot (radioactive) lab facilities
☐ General purpose hood space
☐ Isolated area for behavioral studies (see instructions) Behavior Space.
☐ Other special working space (explain) Other space.
☐ Electron microscope access (approximate number of hours Hours.)
☐ Confocal microscope access (approximate number of hours Hours.)
☐ Two-photon microscope access (approximate number of hours Hours.)
☐ Any other special requirements (explain) Click here to enter text.
c. Laboratory Animals: See Instructions. If using multiple species, provide information for each.
Species required: Species.
i. Do you have prior experience working with this species? yes ☐ no ☐
ii. * If no, please explain how appropriate training will be obtained: Animal Training.
*If species is a vertebrate:
i. Do you have an animal protocol for this species at your home institution or are you named on an
animal protocol covering this species? yes ☐ no ☐
ii. If your application is successful, do you agree to prepare and submit an animal protocol for
approval by the MBL Institutional Animal Care and Use Committee (MBL-IACUC)?
yes ☐ no ☐
Availability of animals: Check as appropriate
Last Name, First Name.
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☐Available from the MBL supply department (http://hermes.mbl.edu/marine_org/marine_supply.html)
☐Available from commercial vendor(s) (give vendor’s name, web or real address): Vendor.
☐Will bring my own (e.g. Zebra Fish, Drosophila)
☐Other (explain)Click here to enter text.
Approximate number of animals needed during Fellowship: Click here to enter text.
Total estimated cost of animals: $ Click here to enter text.
d. Laboratory Supplies and Miscellaneous Expenses: See Instructions; no details are required for
the application.
i. Do you anticipate requiring supplies that exceed $2000 for the summer? (including molecular
biology reagents, fluorescent indicators, core microscopy time)? yes ☐ no ☐
ii. *If “yes”, please explain and estimate the cost Cost overrun.
2. TRAVEL EXPENSES. See Instructions
I/we will be traveling from Start. to Woods Hole before the program and from Woods Hole to End. after
the program.
I estimate the round-trip cost for the following will be (not all categories may apply):
Airfare
#. Adult(s) at $.
Subtotal $ $.
#. Children at $.
Subtotal $ $.
OR
Private vehicle
#. miles at $0.56 per mile
(Note: this is the current 2014 business travel rate;
reimbursement will be made at the 2015 rate)
Subtotal $ $.
*Taxi fare
Click here to enter text.
Subtotal $ $.
*Bus/train fare
Click here to enter text.
Subtotal $ $.
*Estimated expense for lodging and meals en route
#. days at $. per day
*Any other travel-related expenses (explain)
Subtotal $ $.
Click here to enter text.
Subtotal $ $.
TOTAL ESTIMATED ROUND-TRIP TRAVEL EXPENSES: TOTAL: $ $.
3. LIVING ARRANGEMENTS. See Instructions.
a. Housing
Family. Check as appropriate.
☐ I will not be accompanied by any family members.
☐ My spouse/legal domestic partner will accompany me for part or all of the program.
☐My dependent children will accompany me for part or all of the program.
Last Name, First Name.
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*Information on accompanying family member(s) (expand or reduce table as needed).
Name
Relationship to
Applicant #
Name.
Name.
Name.
Name.
Choose an item.
Choose an item.
Choose an item.
Choose an item.
Age
(children only)
Dates in Woods
Hole (approximate)
Age.
Dates.
Age.
Dates.
Age.
Dates.
Age.
Dates.
#
If other than spouse/partner or children, please explain Other Dependents.
Housing Plans. Mark the appropriate response.
☐ I/we plan to live in MBL housing (i.e., shared housing with other Fellows and/or family members).
☐ I/we plan to arrange our own housing and accept all financial responsibility, including any cost above
that of the MBL housing offered (i.e., a cottage shared among three Fellows).
b. Meals
See Instructions; no details are required in the application form.
G. INSURANCE WAIVER. See Instructions.
If selected as a Grass Fellow, the applicant’s signature in Section J indicates that she/he understands
that The Grass Foundation does not pay health or accident insurance, that it is the Fellow’s
responsibility to obtain such insurance through the home institution or other policy, and that the Fellow
waives any claims against The Grass Foundation for illness, accident or injury during the Fellowship
tenure or during travel to and from the program.
H. ADDITIONAL INFORMATION. See Instructions.
Do you have other sources of financial support (e.g., grants) that are available to help finance your
fellowship research and/or personal expenses? yes ☐ no ☐
*If yes, please explain.
Resource.
How did you learn about the Grass Fellowship Program? (please check all that apply)
☐ Advisor
☐ MBL course
☐ MBL website
☐ Former Grass Fellow
☐ The Grass Foundation website
☐ The Grass Fellowship poster/flyer
☐ LAT Program
☐ IBRO School
☐ Scientific Meeting
☐ Advertisement
☐ Listserv
☐ Trustee of The Grass Foundation
☐ Other: If other, please state.
I. DEADLINE & SUBMISSION PROCEDURE. See Instructions. THE CLOSING DATE FOR RECEIPT
OF APPLICATIONS AND LETTERS IS 5 DECEMBER 2014, AT MIDNIGHT EASTERN STANDARD
Last Name, First Name.
5
TIME (UTC -5).
J. ACCEPTANCE OF CONDITIONS.
My signature below confirms that I have read and accept all conditions and policies listed in this Form
FA-2015 and the Grass Fellowship Program Application Instructions, including required dates in
residence. For applicants who are not US citizens or resident aliens, this signature also confirms that
the applicant acknowledges that a valid visa must be held for the entire duration of the program, and
agrees to obtain this visa and required health insurance. In case of holding an H1B, F1, E3 or TN visa
you also agree to submit a valid form GF-H1B, which is available on www.grassfoundation.org.
Click here to enter a date.
____________________________________________________
Sign above
Last Name, First Name.
Last Name, First Name.
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