MDIBL New Investigator Award Application for Space

Deadline for a completed application is January 15, 2008

INSTRUCTIONS: Please refer to the NIA checklist for complete instructions and required elements of a complete NIA application.

Red asterisks (*) indicate required fields. Completion of all fields marked with an asterisk is necessary for the application to be submitted. If you press submit before completing all required fields, your application will not be processed and you will lose all entered data.

Supplementary materials (CV and bibliography, research description) may be uploaded below, received via email, or received via traditional mail by the deadline listed above. Do not FAX supplementary materials.

PLEASE NOTE: If you would like MDIBL housing, please complete the housing application after pressing the "submit" button at the bottom of this page.

Charles Wray, Ph.D.
Associate Administrative Director
MDI Biological Laboratory
Old Bar Harbor Road (Fed Ex Address)
PO Box 35
Salisbury Cove, ME 04672
207-288-2130 (fax)
207-288-9880 ext 125 (phone)
science_apps@mdibl.org
New Investigator Award Application - 2008
I. Personal Information  
First Name*
 Middle Initial
 Last Name*
Degree*
New Investigator Award Year* Gender*

Citizenship*
 Social Security
Home Address*
 City*
 State*
 Zip*
 Country*
Home phone*
 Mobile
 Email*
II. Institutional Information
 
Institution*
 Academic Rank / Title*
Department*
Institutional Address*
City*
 State*
 Zip*
 Country*
Institutional Telephone*
 Institutional Fax*
 Preferred mailing address*
III. Dates for rental of space
 
Please indicate rental periods*

 

Please indicate actual dates at MDIBL.*
Arrival Date: Departure Date:

Please indicate any anticipated absences from MDIBL during this period.
IV. Support
 
Grantor
(NIEHS, NIH, NSF) 		Grant Number and Title
 		Period of Support
Level of Funding Total - Annual $US
V. Research Group

Please list all members of research group. Please have each research group member fill out a Seasonal Personnel Application, available online and on the Forms and Documents page.

Status codes: U, Undergraduate; G, Graduate Student; PD, Post Doc; A, Associate Scientist with Ph.D or MD; HS, High School Student.

Name
 Email Age Gender Status Dates MDIBL Housing







VI. Space and Research Needs

Title of proposed research* (Full research description should be uploaded in Section X., below)

Laboratory preference.* List in order of preference three laboratories in which you would like to work. Review available laboratories.

1.* 2.* 3.*

Laboratories and research requirements. Please describe any special needs (running seawater, compressed gases (mixtures), environmental chambers, ect)

VII. Core and Marine Facilities

Please indicate which facilities you will use.*

General Instrumentation Core Molecular Biology Core
DNA Sequencing Facility Gene Expression Analysis
Confocal Imaging Core Electrophysiology Core
Tissue Culture Facility  
Temperature Percent CO2
Number in Group
   Cell Species
  

Please provide a brief description of use of Tissue Culture Facility (send seperate email to science_apps@mdibl.org if unusual culture requirements are needed). Only animal cells are permitted in Cell Culture Facility.

Please indicate which marine facilities you will use.*

Small Aquaria Tanks Small Specimen Tank
Large Specimen Tank Closed Circulation Tank
VIII. Research Specimens
 
If you intend on using animals not routinely available at MDIBL, please notify Dr. George Kidder, Director Animal Core, MDIBL, via science_apps@mdibl.org. Please indicate the source of your research specimens if they do not come from MDIBL.
Species
 Average Weekly Use Total Summer Use
Source, if not MDIBL
IX. Hazardous Materials Use

Do you plan on using radioisotopes?*

If yes, an Application for Radioisotope Use will be sent to you.

Does (or would) your proposed research require Institutional Biosaftey Committee (IBC) approval at your home institution?*

If yes, please specify:
X. Curriculum Vitae, Research Description, and other supplemental documents

If you wish to directly upload your CV, research discription, or other supplemental documents you may do so here. Please note that all documents need to be combined into one file if they are uploaded here. CV's, research discriptions, and other supplemental documents may also be emailed to science_apps@mdibl.org or mailed to MDIBL via traditional mail at the address above. Please do not FAX these documents.

XI. References (First Year New Investigators Only)

Please list names, addresses, and phone numbers of two references who know your work.

Reference 1   Reference 2
 
XII. Certification

As of today's date, I certify that all information is correct. I will notify the MDIBL Business Office of any changes.

I understand that a $200 non-refundable deposit is required with acceptance of awarded space. Failure to submit deposit may result in reassignment of space. I understand that Principal Investigators assume financial responsibility for all fees incurred by members of their research group.

I accept the terms and conditions stated above and certify that all the information entered on this form is complete and accurate.*

Applicant:* Date:*



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