2017 Applied Research Project Competition Genomics and Precision Health Application Form Application Number: Project Title: Term of Funding (years): Total Budget Requested: Genome Canada Contribution: Project Leader Co-Project Leader (if applicable) Name Name Affiliation Affiliation Address Address Telephone Telephone E-mail E-mail Date Date Signature 2 Certification Requirements Applicants proposing to perform research that requires certification (such as research involving human subjects, human stem cells, animals, biohazards, radioactive materials or possible effects on the environment) must obtain the appropriate certification for the proposed project. Certificates are not required to be provided until after the project has been approved. Please check the box(es) below, if the proposed research involves any of the following: Human stem cells Animals Biohazards Environmental subjects assessment Lead Organization (CEO, President or authorized representative) Organization Name Title Date Signature2 Genome Centre CEO(s) or authorized representative(s) Administrative Co-lead Centre(if Centre applicable) Name Name Date Date Signature2 Signature2 Additional Centre (if applicable) Name Date Signature2 of contents Page
2017 Applied Research Project Competition Genomics and Precision Health Application Form Application Number: Project Title: Term of Funding (years): Total Budget Requested: Genome Canada Contribution: Project Leader Co-Project Leader (if applicable) Name Name Affiliation Affiliation Address Address Telephone Telephone E-mail E-mail Date Date Signature Certification Requirements Applicants proposing to perform research that requires certification (such as research involving human subjects, human stem cells, animals, biohazards, radioactive materials or possible effects on the environment) must obtain the appropriate certification for the proposed project. Certificates are not required to be provided until after the project has been approved. Please check the box(es) below, if the proposed research involves any of the following: Human subjects stem cells Animals Biohazards Environmental assessment Lead Organization (CEO, President or authorized representative) Organization Name Title Date Signature2 Genome Centre CEO(s) or authorized representative(s) Administrative Centre Co-lead Centre(if applicable) Name Name Date Date Signature2 Signature2 Additional Centre (if applicable) Name Date Signature2 of contents Page 2
2017_lsarp_full_application_form_final_july_2017.docx