INDICATE MAJOR AREA(S) FOR REVIEW (CHOOSE UP TO 3):
Animal Model
Bioinformatics
Cell Biology
Early
Detection
Etiology/Pathophysiology
Genetics/Epigenetics
Genomics/Proteomics/Metabolomics
Immunology
Novel
Therapy
Prevention
Stem Cells
Tumor
Microenvironment
Other (please specify):
Marsha Rivkin Center for Ovarian Cancer Research
Grant Application
Do not exceed character length restrictions indicated.
1. TITLE OF PROJECT (Do not exceed 128 characters, including spaces and punctuation.)
2. IN RESPONSE TO SPECIFIC REQUEST FOR APPLICATIONS FOR:
PILOT STUDY AWARD
SCIENTIFIC SCHOLAR AWARD
CHALLENGE GRANT AWARD
BRIDGE FUNDING AWARD
2a. Has this project been submitted previously to the Rivkin Center?
No
Yes
3. PROGRAM DIRECTOR/PRINCIPAL INVESTIGATOR
2a. If yes, what year?
3a. NAME (Last, First, Middle)
3b. DEGREE(S)
3h. eRA Commons User Name
3c. POSITION TITLE
3d. MAILING ADDRESS (Street, city, state, zip code)
3e. DEPARTMENT, SERVICE, LABORATORY, OR EQUIVALENT
3f. MAJOR SUBDIVISION
3g. TELEPHONE AND FAX (Area code, number, and extension)
TEL:
E-MAIL ADDRESS:
FAX:
4. HUMAN SUBJECTS RESEARCH
No
4a. Research Exempt
Yes
No
4b. Federal-Wide Assurance No.
No
Yes
5a. Animal Welfare Assurance No.
Yes
6. DATES OF PROPOSED PERIOD OF
SUPPORT (month, day, year—MM/DD/YY)
From
Yes
4c. Project Designed to Analyze Data from an Already Funded Clinical Trial?
No
5. VERTEBRATE ANIMALS
If “Yes,” Exemption No.
Through
7. COSTS REQUESTED FOR FIRST YEAR
(Challenge Grant Only)
Direct Costs ($)
9. APPLICANT ORGANIZATION
Name
8. COSTS REQUESTED FOR PROPOSED
PERIOD OF SUPPORT
Direct Costs ($)
10. TYPE OF ORGANIZATION
Address
Public:

Federal
Private:

Private Nonprofit
State
Local
For-profit: 
11. ENTITY IDENTIFICATION NUMBER (Required for all U.S.
based entities. Non-U.S. based entities with EINs are encouraged to
provide this number.)
12. ADMINISTRATIVE OFFICIAL TO BE NOTIFIED IF AWARD IS MADE
Name
13. OFFICIAL SIGNING FOR APPLICANT ORGANIZATION
Name
Title
Title
Address
Address
Tel:
FAX:
Tel:
FAX:
E-Mail:
E-Mail:
14. APPLICANT ORGANIZATION CERTIFICATION AND ACCEPTANCE: I certify that
the statements herein are true, complete, and accurate to the best of my knowledge and
accept the obligation to comply with Marsha Rivkin Center for Ovarian Cancer Research
terms and conditions if a grant is awarded as a result of this application. I am aware that
any false, fictitious, or fraudulent statements or claims may render the institution and/or
investigator ineligible for future funding from the Rivkin Center.
SIGNATURE OF OFFICIAL NAMED IN 13. (In ink)
MRC (Rev. 09/14)
Face Page
DATE
Form Page 1