2016 Award Application
Syngenta Fellowship Award in
Human Health Applications of New Technologies
Please use no less than 10 point font, maintain the given margins, and use no more than the specified pages.
Name
Current Address
City/State/Zip
Phone
FAX
E-mail
Institution at which research will be performed
Department
Address
City/State/Zip
For Graduate Student applicants:
List Graduate and Undergraduate Academic Training (most recent first)
Institution
Dates
Title
Name of Research Advisor
Title
Name of recommender 1
Title
Name of recommender 2
Degree
Area or Major
List the other two recommenders, apart from your research director, who will submit letters of reference on your behalf.
Please forward the recommendation forms to them.
Anticipated date of dissertation defense
For Postdoctoral Trainee applicants:
Name
Postdoctoral
Program Director
The above signature indicates that the applicant has been accepted into your program or will be accepted if an award is made.
Institutional officer responsible for sponsored research programs at which the training will occur
Title
Name
Signature
Doctoral Institution
If degree is
completed
If degree is in
progress
Doctoral
Advisor
Degree Awarded
Date Awarded
Degree
Anticipated date of dissertation defense
1
Date
Your complete application will include:
1. Application form—including a description of research to be performed. Candidates shall articulate how their work
provides data that will permit a quantitative basis for extrapolation of the results from animal studies to human at
relevant human doses.
2. Curriculum vitae
3. Reprints of up to three representative publications or abstracts if available. The items above are uploaded at the
Awards Web site.
4.
Letter of reference from advisor.
5. Two additional letters of reference; request that letters of recommendation be sent by recommenders to
sothq@toxicology.org using “Syngenta Fellowship” in subject line.
Documents #1-3 above will be uploaded via the Awards page of the SOT website at www.toxicology.org
no later than October 9, 2015.
Send a signed copy of this form to Syngenta Fellowship, c/o SOT Awards Committee, Society of Toxicology, 1821 Michael Faraday
Drive, Suite 300, Reston, VA 20190. This must arrive at SOT by October 9, 2015.
I have read the stipulations, terms and conditions for the Syngenta Fellowship Award and hereby submit my application to SOT Headquarters.
Date
Applicant Signature
Date
Signature of
Research Advisor
2
Proposed Budget
Syngenta Fellowship Award in
Human Health Applications of New Technologies
Please provide all information in no more than one page in 10 point font.
Applicant
Title of Position
Budget period (month/year)
Salary
From
From Grantee Institution
To
From Fellowship Award
Salary
Fringe
TOTAL
Other Sources of Funding for Candidate
Expendable Supplies (list individual items that cost over $100 each)
$
$
$
TOTAL
$
Permanent Equipment (over $500)
Item
Justification
Cost
$
$
TOTAL
$
TOTAL
$
Other expenses (list individual items)
$
$
Total direct costs
Indirect costs (may not exceed 8%)
$
$
TOTAL AMOUNT REQUESTED (up to $15,000)
$
Provide an abstract containing a brief description of the project in terms understandable to readers without specialized
knowledge in the area of research (maximum length = 200 words).
In no more than 1 page, articulate how your work provides data that will permit a quantitative basis for extrapolation of the
results from animal studies to human at relevant human doses.
3