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Grant Application

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1. Name, address, education, position, university/hospital affiliation, list of publications:

2. Amount requested:

3. Title of research project:

4. Summary (500 word limit) of proposed research (summary should be completed on this page, although additional supporting documentation including investigational design and expected results should be attached):

5. Outline of proposed budget. This should be detailed and itemized including personnel, equipment, supplies and other expenses. Each category should include a justification.

Should this proposal be accepted, and a grant funded, the undersigned hereby agrees to give a written statement within two months of completion of the project or within a 10-month period from the first funding of the grant.

The follow-up statement shall include: A) What was accomplished? B) Were the initially stated goals accomplished? C) How were the funds spent? D) Are the results being prepared for publication? E) If so, where will they be submitted for publication?

Grantee agrees to acknowledge the Burn Institute in the publishing of any literature, and that the Burn Institute shall be provided with any literature published as a result of the grant within one month of its publication date.

Date ________________ Signature _____________________________

INSTRUCTIONS:
Please type your answers to these questions on a separate piece of paper and send to:

Burn Institute
8825 Aero Drive, Suite 200
San Diego, CA 92123-2269