Specific Defect Application 2023 50d5a07b02
Specific Defect Application 2023 50d5a07b02
Specific Defect Application 2023 50d5a07b02
Institution: _________________________________________________________________
_________________________________________________________________
Address: _________________________________________________________________
_________________________________________________________________
_________________________________________________________________
Telephone: _________________________________________________________________
Fax: _________________________________________________________________
Title: _________________________________________________________________
_________________________________________________________________
Project Summary (Please provide a brief description of your proposed research project,
highlighting the objective of the research and specific aims):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Proposed Project Period
(Maximum 2 Year Duration): __________________________________________________________
Mandatory Attachments:
3. CV Yes No
I certify that the statement and all of the above information are accurate and complete to the
best of my knowledge. I agree to comply with the terms of the conditions of the award if issued.
I am aware that any fraudulent statements or claims may be subject to penalties and immediate
dismissal from the Program. I will acknowledge the Jeffrey Modell Foundation in all materials
and publications that result from the Program. I agree to all of the above terms by signing this
application.