FASIC FELLOWSHIPS 2016
APPLICATION FORM
To be submitted by the research/grants office (or equivalent)
NOTE: Please type as handwritten applications will not be accepted. Please set the text size at 12pt. All sections on this form should be completed. You are not limited to the space provided below and unless otherwise stated you can expand the items below as you see fit. Attachments should be added only where required. 
SECTION 1: Applicant
1.	Full name and title (Upper case for surname):
Title	First name	Surname	
     	     	     	
2.	Contact details:
Position:	     	
Department:	     	
Organisation	     	
Organisation’s postal address:	     	
Email address:	     	
Phone number:	     	
Fax number:		     	
3.	Date and place of birth:
Date of birth:	     	
Place of birth:	     	
4.	ECR is an:
Australian citizen:			     
OR
Australian permanent resident:	     	

If you are an Australian citizen OR Australian permanent resident and were not born in Australia – please provide proof of Australian citizenship/Australian permanent residency status e.g. Citizenship certificate, passport and/or passport and visa.
(Please attach supporting documentation at the end of application)	
5.	PhD degree (or equivalent research doctorate) details:
(Must have been received within fifteen (15) years)
Year awarded:	     	
Institution:	     	
State/Country:	     	
Field/s of research:	     	
(Please attach supporting documentation at the end of application)
6.	Where did you find out about the Academy's program?
Please tick one	 Academy email register
 Academy mailing list
 Employer’s noticeboard or newsletter
 Other
Please describe:      	
7.	Please indicate the most relevant Field of Science that your research falls under. (full list can be found after Guidelines for Applicants)
Field of Science	     	
Speciality	     	
If multidisciplinary, please indicate other relevant fields.
Field of Science	     	
Speciality	     	

SECTION 2: Details of Activities
8.	Brief title of proposal (in no more than 20 words).
The summary should be written in a style understandable for the intelligent layperson and suitable for a press release.
(No more than 20 words)
      	
9.	Description of proposal:
In no more than one A4 page, describe the proposal in terms of what will be undertaken, where and with whom.
(Maximum length one A4 page – this text box will expand)
     	
10.	Selection Criteria:
In no more than two A4 pages, describe how the project will support you, to develop sustainable research networks and linkages, taking account of the:
•	scientific merit of the research (including the value of collaboration with France)
•	demonstrated achievements of the applicant in the context of his/her career to date
•	leading edge research capacity of the proposed host researcher and institution
•	expected outcomes intended to support the program’s focus and objectives including the commercial or public good application of research and journal publications
•	value of the expected outcome of the research project to Australian science. 
(Maximum length two A4 pages – this text box will expand)
     	

Evidence to support the claims should include:
•	a copy of your CV (no more than 2 pages each); and
•	a 1 page statement detailing the track record of the your home institution in the specified field of research.
(Please attach supporting documentation at the end of application)
Program details
11.	Total time spent on program
(Travel to France may commence from 1 August 2016 onwards and must be for a minimum of 14 days, maximum of 28 days. All travel must be completed by 30 April 2017)
     	
12.	Projected commencement and completion dates:
(Travel to France may commence from 1 August 2016 onwards and must be for a minimum of 14 days, maximum of 28 days. All travel must be completed by 30 April 2017)
Projected commencement date:	     	
Projected completion date:	     	
13.	Projected expenditure
Successful applicants may receive from the Academy a grant-in-aid of up to AUD$5,000 towards the cost of an international return economy airfare from Australia to the international airport closest to the host institution and domestic travel within France and domestic travel (up to a maximum of $2,500) and a daily living allowance (for accommodation and living expenses) of $200 per day or a maximum of up to $2,500 (whichever is the lesser amount). Please note that the grant-in-aid is not transferable.
Please provide the requested amounts that you are applying for:	
Return economy airfare = 
(Including domestic travel within France)	AUD$     
(up to a maximum of $2,500)	
Number of days = 	      days
(Min of 2 weeks)	
Living Allowance = 
(Number of days X $200 per day; up to maximum of $2,500)	AUD$     
(Max $2,500)	
TOTAL amount requested =	AUD$	     
(Up to a maximum of $5,000)	
SECTION 3: FRENCH HOST RESEARCH INSTITUTION/S
14.	French research institution/s
Please include contact information for each French research institution to be visited. 
a)	Name and address of institution:
Institution name:	     	
Physical address:	     	
Postal address:	     	
Main/switchboard:	     	
Name and position of individual who will be point of contact:
Name:	     	
Position	     	
Department:	     	
Phone number:	     	
Fax number:	     	
Email:	     	
Please attach a letter from your host inviting you and commenting on the proposed collaboration. (Please attach supporting documentation at end of application)
b)	Name and address of institution
Institution name:	     	
Physical address:	     	
Postal address:	     	
Main/switchboard:	     	
Name and position of individual who will be point of contact:
Name:	     	
Position	     	
Department:	     	
Phone number:	     	
Fax number:	     	
Email:	     	
Please attach a letter from your host inviting you and commenting on the proposed collaboration. (Please attach supporting documentation at end of application)
SECTION 4: REFEREES
15.	Referee Information
a)	Name, address and contact details of one referee (Australian or overseas) who will complete the Referee Report form. Only one written reference is required. 
Full name and title
(Upper case for surname)	     	
Organisation	     	
Department	     	
Postal address	     	
Email address	     	
Phone number	     	
Fax number	     	
(Please attach supporting documents at the end of the application)
b)	Names, addresses and contact details of two additional referees (Australian) who may be contacted by the selection committee if further information is required. Additional referees are not required to provide a written referee report.
Additional referees should not be from the applicant’s department or division, or from the host institution.  
Full name and title
(Upper case for surname)	     	
Organisation	     	
Department	     	
Postal address	     	
Email address	     	
Phone number	     	
Fax number	     	

Full name and title
(Upper case for surname)	     	
Organisation	     	
Department	     	
Postal address	     	
Email address	     	
Phone number	     	
Fax number	     	
IMPORTANT NOTICE
16.	Only applications submitted by a research office or, if from the private sector, grants manager, will be considered. It is the research office/grants manager’s responsibility to ensure that all the necessary documents have been submitted.  Incomplete applications may be excluded from the selection procedure.
17.	The Academy will acknowledge receipt of this application within 48 hours following the grant deadline. If you do not receive acknowledgement that this application has been received please contact the Academy immediately. No late applications will be accepted.
18.	Applications are considered carefully against the selection criteria by a committee of scientists with diverse expertise. The decisions of the committee are based upon the assessed competitiveness of the proposal. The Academy is not able to enter into discussion or correspondence regarding the reasons why an application is successful or not.

Signature of applicant:	

Name:		
Date:		

FASIC FELLOWSHIPS 2016
GUIDELINES FOR APPLICANTS
Deadline for applications:	5 pm (AEST) Saturday 30 April 2016
Lodging your application:	Complete the application form and submit it electronically to: grants@science.org.au 
Attach supporting documents: 1.	Proof of Australia citizenship/Australian permanent residency (only for applicants not born in Australia) 
2.	Copy of PhD Degree
3.	Curriculum Vitae or track record
4.	Statement detailing the track record of the home institution in the specified field of research
5.	Letter/s of invitation from the host institution/s
7.	Referee report
Receipt of application form:	The Academy will acknowledge receipt of this application within 48 hours following the grant deadline. If you do not receive acknowledgement that this application has been received please contact the Academy immediately. No late applications will be accepted.
Deadline for referee reports:	5pm (AEST) Saturday 30 April 2016 (The referee report should be sent to the research/grants office or directly to the Academy). Refer to the Notes for Referees for details.
Notification of outcome:	The Academy expects that all applicants will be notified of the outcome in July 2016.
Contact:	E-mail: grants@science.org.au

PLEASE DO NOT SEND APPLICATION FORMS BY FACSIMILE
NO LATE APPLICATIONS WILL BE ACCEPTED	

Fields of Science
Science	Speciality	
Agricultural Sciences	•	Animal Production
•	Crop and Pasture Production
•	Environment Sciences
•	Fisheries Sciences
•	Forestry Sciences
•	General
•	Horticulture
•	Land, Parks and Agriculture Management
•	Other
•	Other (Aquaculture)
•	Soil and Water Sciences
•	Veterinary Sciences	
Applied Sciences and Technologies	•	Aerospace Technologies and Engineering
•	General
•	Industrial Biotechnology & Food Sciences
•	Manufacturing, Process Technologies & Engineering
•	Material Sciences & Technologies
•	Other
•	Other (Photonics)	
Biological Sciences	•	Biochemistry and Cell Biology
•	Biotechnology
•	Botany
•	Clinical Chemistry
•	Clinical Sciences
•	Ecology (and evolution)
•	General
•	Genetics, Molecular Biology and Biotechnology
•	Health Services
•	Medical Biochemistry
•	Medical Microbiology
•	Microbiology
•	Neurosciences
•	Oncology
•	Other
•	Other (Aquaculture)
•	Other (Bioinformatics/Computational Biology)
•	Other (Biophysics)
•	Other (Cell Biology, Immunohistochemistry)
•	Other (Comparative Animal Physiology)
•	Other (Environmental Microbial Ecology)
•	Other (Forensic Science)
•	Other (Molecular Microbiology)
•	Other (Structural Biology)
•	Pharmacology
•	Physiology
•	Public Health
•	Zoology	
Chemical Sciences	•	Analytical Chemistry
•	General
•	Inorganic Chemistry
•	Macromolecular
•	Organic Chemistry
•	Other
•	Other (Biological Inorganic Chemistry)
•	Other (Biomaterials)
•	Other (Chemical Oceanography)
•	Other (Material Conservation)
•	Other (Polymers/Biomaterials)
•	Other (Surface Chemistry)
•	Other (Wine Science)
•	Physical Chemistry (Inc. Theoretical & Structural)
•	Theoretical and Computational	
Earth Sciences	•	Atmospheric Sciences
•	General
•	Geochemistry
•	Geography
•	Geology
•	Geophysics
•	Hydrology
•	Oceanography
•	Other
•	Other (Antarctic Palaeoclimatology)
•	Other (Archaeology)
•	Other (Biogeochemistry)
•	Other (Costal/environmental Hydrodynamics)
•	Other (Geodynamics)
•	Other (Palaeontology)
•	Other (Paleoclimatology)
•	Other (Satellite Geodesy)
•	Other (Space Science)
•	Other (Vertebrate Palaeontology)	
Engineering and Technology	•	Aerospace Engineering
•	Automotive Engineering
•	Biomedical Engineering
•	Chemical Engineering
•	Civil Engineering
•	Communications Technologies
•	Computer Hardware
•	Electrical & Electronic Engineering
•	Environmental Engineering
•	General
•	Industrial Biotechnology and Food Services
•	Interdisciplinary Engineering
•	Manufacturing Engineering
•	Maritime Engineering
•	Materials Engineering
•	Mechanical and Industrial Engineering
•	Metallurgy
•	Mining & Mineral Processing
•	Other
•	Other (Architectural & Urban Engineering)
•	Other (Combustion Engineering)
•	Other (Construction Management and Innovation)
•	Other (Energy Engineering)
•	Other (Energy Planning and Policy)
•	Other (Environmental Engineering)
•	Other (Geomatics, Mapping, Remote Sensing)
•	Other (Hydrogen Energy Systems)
•	Other (Nanotechnology)
•	Other (Renewable Energy Engineering)
•	Other (Transport Systems Engineering)
•	Petroleum Engineering
•	Resources Engineering	
Environment Management	•	Environmental Management
•	Other
•	Other (Geographical Information Science)	
IT, Computer & Communications Technologies	•	Artificial Intelligence, Signal & Image Processing
•	Communication Technologies
•	Computation Theory and Mathematics
•	Computer Hardware
•	Computer Software
•	Data Format
•	General
•	Information Systems and Technologies
•	Other
•	Other (Computer Graphics and Virtual Reality)
•	Other (Geospatial Information Sciences)
•	Other (Optimisation methods in Telecommunication)
•	Other (Robotics)
•	Other (Wearable Computing/Augmented Reality)
•	Other (Web Services)
•	Other information, Computing & Communication	
Mathematical Sciences	•	Applied Mathematics
•	General
•	Other
•	Other (Operations Research)
•	Other (Systems Theory)
•	Pure Mathematics
•	Statistics	
Medical and Health Sciences	•	Clinical Sciences
•	Complimentary/Alternative Medicine
•	Dentistry
•	General
•	Health Services Research
•	Human Movement and Sports Science
•	Immunology
•	Medical Biochemistry and Clinical Chemistry
•	Medical Microbiology
•	Medical Physiology
•	Neurosciences
•	Nursing
•	Optometry
•	Other
•	Other ( Orthopaedics)
•	Other (Behavioural Neuroscience/Experimental Psych
•	Other (Clinical Psychology)
•	Other (Fibre Optic Medical Imaging/ Endoscopy)
•	Other (Forensic Dentistry)
•	Other (Gastronenterology)
•	Other (Molecular Parasitology)
•	Other (Nuclear Medicine)
•	Other (Oncology)
•	Other (Ophthalmology)
•	Other (Proteomics)
•	Other (Psychology)
•	Other (Rehabilitation)
•	Other (Speech Pathology)
•	Other(Psychology)
•	Pharmacology & Pharmaceutical Sciences
•	Public Health Research	
Physical Sciences	•	Acoustic & Optical Physics
•	Astronomical Sciences
•	Atomic, Molecular, Nuclear, Particle & Plasma
•	Classical Physics
•	General
•	Other
•	Other ( Space Science: Ionospheric/Magnetospheric
•	Other (Biological Physics)
•	Other (Optical Physics)
•	Other (Quantum Optics)
•	Other (UV Measurement)
•	Theoretical and Condensed Matter Physics	
Social Sciences and Humanities	•	General