FORM ‘B’Call 2022 for the submission of grant requests for research projects in the "Scientific and Technological Research" Sector 

Project proposal for research activities in the scientific macro-area of :

- Biomedicine -

Second selection phase

Principal Investigator and coordinator of the Project (PI)	
Name
Surname
Institution:
Qualification at the Institution:

Contacts: 
Mailing address
Telephone
Mobile telephone
Email address	

PI membership organization and qualification/function in the organization	
Membership organization:
Legal representative
Mailing Address
Telephone
Fax
Email address

PI position in the Organization (if any):

PI Reference structure (Department, Institute..)
Legal representative
Mailing Address
Telephone
Fax
Email address

PI position in the Reference structure (if any):

This Organization:
denomination …………………………………………………………………
registered office ………………………………………………………………
tax code ……………………………………………………………………….
legal representative ……………………………………………………………

as Applicant Entity assuming the proposed project’s ownership in case of its admission to contribution by Fondazione Pisa, transmits Form 'B'.

Title of the Research Project	

Key words
Max 6 	

Scientific hypothesis to be investigated
Max 1.500 characters spaces included	

Rational basis of the scientific hypothesis to be investigated 
Max 12.000 characters spaces included	
Scientific background:
Preliminary data:
…..	

Detailed description of the innovative contents of the Project, also including its placement in the current context of research in the same field	
Max 6.000 characters spaces included	

Project’s final goals analytical description, also including any milestones	
Max 4.000 characters spaces included	

Potential applications of the results of the Project in order to achieve appreciable social and/or economic utility, also with regard to the possible impact on the Foundation’s area 	
Max 4.000 characters spaces included	

Detailed description of research activities, methods and technologies that you intend to use	
Max 4.000 characters spaces included	

Phases of the research program, describing their scheduling and information as to the content as well the intermediate controls	
Max 4.000 characters spaces included	
Total duration of the project in months n. …..	
Articolation of phases	Content of the single phase	

from n0 month to n1 month		

from n2 month to n3 month		

from n4 month to n5 month		

from n6 month to n7 month		

from n8 month to n9 month		

Public and/or private bodies involved in the project with the analytical representation of the content of their participation	
For each Institution (Applicant Entity included) indicate:
Denomination …………………………………………………………………
Registered office ………………………………………………………………
Structure/s involved …………………………………………………………..
Reference researcher (for Applicant Entity it coincides with the PI and Coordinator of the project) …………………………………………………………….
Kind of specialized contribution based on prior experiences in the specific field of research:
…………………………………………………………………………………………………..

Available Equipment: …………………………………………………………………………..
for a total value of € ……………….. due to the use.

Research staff:
name and surname (if known at the moment)
specialistic and professional skills: 
area/module of the Project in which the specialist should be called to work:
planned man-months: 
full time YES or part time for …… hours per day.(in attach CV)
For a full-cost of € …….

Cash contribution of € ...............................................................

Rate of contribution compared to the Project total cost …….%

Researchers and/or specialists (ie not organic to Institutions) that are expected to call to collaborate in the realization of the Project	
For each one, please indicate
Name and surname:
Specialized and professional skills (in attach scientific CV, highlighting the scientific publications of the last five years): 
Area/module of the Project in which the specialist should be called to work: 
Planned months/man: 
Full time YES or part time for …… hours/day.
Overall remuneration: 	

Describe the administrative management of the project and the resources assigned to this function	
Max 3.000 characters spaces included	

Public authorizations required and any kind of relationship, contact or connection with the public authorities that the Project makes it possible and/or necessary	

Project Financial Plan

Total cost of the project 
	= €	

Revenue (cash and/or valued goods and services) 	Cash	Valued goods and services	
Contribution from Institution 	€	€	
Contribution from Institution	€	€	
Contribution from Institution	€	€	
Contribution from Institution	€	€	
Contribution from Fondazione	€		
Total revenue                    	= €	

Eligible costs borne by Foundation	
Cost item	Reason for and source 	Cost*	
1. New equipment 
a)
b)
…		
€
€
€	
2. Full time research staffspecifically recruited for the project
a) 
b) 
…		
€
€
€	
3. Part time research staff time specifically recruited for the project

a)
b)
...		

€
€
€	
4. Technical or professional services:
a)
b)
...		

€
€
€		
5. Research/scientific trip:
a)
b)
...	
	
€
€
€	
6. Scientific publications:
a)
b)
...		
€
€
€	
7. Royalties/licenses/patents:
a)
b)
...		

€
€
€	
8. Expendable:
a)
b)
...		
€
€
€	
Total		€ ………………….. equal to ….. % of the project overall cost 	

(*) Cost means costs, before tax, duties and contributions, paid for the purchase of new goods and services.

Costs borne by Applicant Entity and its Partners	
Cost item 	Cash	Valued goods and services	
a.	Applicant Entity and Partners’s personnel
-		€	
b.	Other
		€	
Total	€ ………………….. equal to ….. % of the project overall cost 	

Schedule of costs 	
	Year 1	Year 2	Year 3	
Cost item per year	Cash	Goods and services	Cash	Goods and services	Cash	Goods and services		

							

							

							

							
Total €							

***   ***   ***
It is recognized that, by receiving this Form, the Foundation does not assume any obligation towards the sender Entity.

The undersigned legal representative of the Applicant Entity declares that the organization will take responsibility for the management and operation of the project and of the planned research activities, relieving the Foundation from any liability towards third parties.

In addition, the undersigned legal representative declares that, in case of funding of the Project, the organization is willing to sign a specific agreement, submitted by the Fondazione, to discipline the relationship that should result, including rules concerning the use and the industrial or commercial exploitation of any practical applications of the results.
According with Legislative Decree no. 196/03 and s.a.a., the undersigned legal representative agrees to  the use of the data included in this Form for purposes related to the investigation of the Project assessment and declares under its own responsibility to have fulfilled the obligations imposed by the aforementioned legislation regarding data supplied by the organizations and participants mentioned.

Place/Date

____________________
 Applicant Entity Legal Representative
Signature 
Name _________________________

Surname _______________________

Signature _______________________