Application summary. Lead applicant. Application title. What stage of Fellowship are you applying for? Proposed duration of funding (months)

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1 Application summary Application title What stage of Fellowship are you applying for? Proposed duration of funding (months) Proposed start date Name of administering organisation Lead applicant's address at administering organisation Department/Division Organisation Street City/Town Postcode/Zipcode Country Research funding area Please select from the drop-down list the funding area that you consider your research falls under Lead applicant Lead applicant details Full Name Department Division Organisation Page 1 of 6

2 Address Line 1 City/Town Postcode Country Telephone No. Address Career history (current/most recent first) From To Position Organisation Source(s) of personal salary support Current/last appropriate salary details Basic salary (per annum) Currency Date of last increment Education/training From To Qualification Subject Organisation Have you obtained or registered for a higher degree, e.g. PhD, MD or equivalent? Please specify degree type, university and date of completion Career breaks Have you had any career breaks or periods of part-time work, for example parental or long-term sick leave? Please provide details Page 2 of 6

3 Do you wish to undertake this award part time? Career contributions What are your most important research-related contributions to date? This may include contributions to health policy or practice, or to technology or product discovery and development. (350 words max.) Personal statement Describe how this Fellowship will further your research and career aspirations, and its context in your longer-term vision. (500 words max.) Professional recognition Please list: (i) Prizes, honours and awards received during your career, including invited talks during the last three years; (ii) Current memberships of funding agency advisory and/or journal editorial boards. Peer-reviewed publications and other research outputs List up to 20 of your most significant peer-reviewed publications, preprints, or other scholarly research outputs, e.g. patents. You may provide a summary of your contribution to, or your role in, the work associated with each (e.g. intellectually conceiving or conducting the research, supervising staff, writing the paper). Publications should be in chronological order with the most recent first. Please give citation in full, including title of paper and all authors*. Citations to preprints should state Preprint, the repository name and the articles persistent identifier (e.g DOI). Page 3 of 6

4 (*All authors, unless more than 10, in which case please use et al, ensuring that your position as author remains clear.) Total number of peer-reviewed publications which you have authored/coauthored. Please exclude abstracts and literature reviews. Current and recent research funding (including Wellcome Trust grants) Please list all held in the last five years and any key prior grants (list the most recent first). State the name of the awarding body, name(s) of grantholder(s), title of project, amounts awarded, your role in the project, and start and end dates of support. For all active grants, indicate the number of hours per week that are spent on each project. Clinical status Please indicate whether you are a medical or dental graduate; a veterinary graduate; or a clinical psychologist What clinical contract and post (e.g. Clinical Lecturer) do you currently hold, and what is your current stage of clinical training (e.g. ST4, ST5, etc.)? What is your specialty? Please specify Do you hold a Certificate of Completion of Training (CCT)? Page 4 of 6

5 State date awarded When do you anticipate this will be obtained? Do you intend to integrate dedicated periods of clinical training into the Fellowship? Please describe your plans for the integration of your clinical training into your Fellowship. For each year of the Fellowship you should indicate the average number of hours per week spent on training, and the source of personal salary support. Please state the number of hours per week of clinical duties (not including formal training) required to maintain your competencies as a practitioner. Sponsor 1 Name, including title (e.g. Professor, Dr) Current position Department Organisation Country Expected date of termination of post Supporting statement from sponsor Please upload a letter of support from your sponsor Page 5 of 6

6 Other organisations Please detail any other organisations where work will be undertaken during your Fellowship. If research sponsors in these locations have been identified, give brief details here. Details of project Research proposal (700 words maximum) Please outline your proposed research, including key goals. (700 words max.) Approximate costs Applicant's salary (including employer's contributions) Other salary requests Materials and consumables Animals Equipment Miscellaneous costs Total ( ) Page 6 of 6

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