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Core Service Application Form
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Core Services – Investigator Information
Name
Email
Title
Title
- Select -
Chair
Professor
Associate Professor
Assistant Professor
Research Scientist
Other…
Enter other…
If you selected 'other' please indicate your preferred professional title or add an additional professional title if applicable.
Select the title that most closely describes your primary professional role.
Institution
Institution
- Select -
American University
Children's National Medical Center
Georgetown University
The George Washington University
Howard University
Veterans Affairs Medical Center
DC Health
Whitman Walker
Us Helping Us
Other…
Enter other…
If you selected 'other' please indicate your institutional affiliation.
Are you a full investigator member?
Yes
No
Project Information
Project Title
Project Description
Include the proposed use of DC CFAR Core services. (250 word maximum.)
Potential for Future NIH Funding
Describe how the proposed support will lead to future projects or NIH grant applications. (100 word maximum.)
Statement of Work
Provide a statement of work for the requested funds.
Letter of Support
Attach a letter of support from the relevant Core Laboratory/Service Director describing how the services will support the project and the Core Laboratory/Service Director will help future development of the project.
One file only.
256 MB limit.
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Cover Letter
Attach a cover letter signed by the applicant and Department Chair.
One file only.
256 MB limit.
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Budget Information
Budget Justification
Provide a brief budget justification. (100 word maximum.)
Regulatory Documentation
If applicable, attach relevant regulatory documentation (e.g. IACUC, IRB).
One file only.
256 MB limit.
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Quote
Billing Information- Institution Supplying Service
Institution Name
Manager Name
Billing Address (where checks should be mailed)
City/State/Zip
Phone
Email
Investigator Information- Supplying Service
Institution Name
Investigator Name
Phone
Email
The manager of the investigator supplying services has reviewed this request and concurs with the quote provided below.
Yes
No
Investigator Information- Receiving Service
Institution Name
Investigator Name
Phone
Email
The investigator receiving services has reviewed this request and concurs with the quote provided below.
Yes
No
Description of Services
Please download the microgrant budget template, fill out, and upload here.
One file only.
256 MB limit.
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