Phone + Fax E-mail address 3. Project title: 4. Project acronym: 5. Project coordinator (research partner # 1 in the multinational research consortium): Name Country Position Institution/Department Address + Fax E-mail address Type of entity ☐Academia ☐Public (tick as appropriate) ☐Clinical or Public Health ☐Private-for-profit ☐SME or Industry ☐Private-non-for-profit 6. Other research partners: Type of entity Institution, Name of research Phone & Email Public, Country department & Academia, Clinical/ No. partner (principal or Fax address Public Health or full address investigator) Industry/SME 2 3 4 5 6 Signature of the Principal Investigator Signature of the Authorized Legal Representative Date
Phone + Fax E-mail address 3. Project title: 4. Project acronym: 5. Project coordinator (research partner # 1 in the multinational research consortium): Name Country Position Institution/Department Address + Fax E-mail address Type of entity (tick as appropriate) ☐Academia ☐Public ☐Clinical or Public Health ☐Private-for-profit ☐SME or Industry ☐Private-non-for-profit 6. Other research partners: No. Country Name of research partner (principal investigator) Institution, department & full address Phone & Fax Email address Type of entity Academia, Clinical/ Public Health or Industry/SME Public, or 2 3 4 5 6 Signature of the Principal Investigator Signature of the Authorized Legal Representative Date
IT-RER-ASSR_pre-submission_eligibility_check_JTC-2015.docx