3. Project title: 4. Project acronym: 5. Project coordinator (research partner 1 in the multinational research consortium): Name Country Position Institution/Department Address Phone + Fax E-mail address Type of entity ☐Academia ☐Public (tick as appropriate) ☐Clinical ☐Private-for-profit or Public Health ☐SME or Industry ☐Private-non-for-profit 6. Other research partners: Type of entity Institution, Name of research Phone & Email Public, No. Academia, Clinical/ Country department & 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 authorised legal represent Date
3. Project title: 4. Project acronym: 5. Project coordinator (research partner 1 in the multinational research consortium): Name Country Position Institution/Department Address Phone + 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 authorised legal represent Date
5_IT_MoH_pre-submission_eligibility_check_JTC-2015.docx