2012 CURE Multidisciplinary Award
Letter of Intent (LOI)

2-year award for up to $350,000

Deadline for receipt: December 13, 2011. This is an interactive form. Please type directly into this form. Form accepts text only. If you have previously started the application and wish to continue where you left off, please enter your Email address and hit the "Load" button.

Email:       Project Title:

1st Co-Investigator (required)

Name:    first    middle    last

Degree(s): Academic Position: Institutional Affiliation: Department:

Address 1: Address 2: Address 3:

City: State: - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip:

Country:

Telephone: Fax:

Additional Research Support: list funding source, amount of funding, and date of all received, requested, and anticipated funding:

Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date:

I am an: Early Career Investigator Established Investigator

2nd Co-Investigator (required)

Name:    first    middle    last

Degree(s): Academic Position: Institutional Affiliation: Department:

Address 1: Address 2: Address 3:

City: State: - AB AK AL AR AZ BC CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NB NC ND NE NF NH NJ NM NS NT NV NY OH OK ON OR PA PE QC RI SC SD SK TN TX UT VA VT WA WI WV WY YT Zip:

Country:

Telephone: Fax:

Email:

Additional Research Support: list funding source, amount of funding, and date of all received, requested, and anticipated funding:

Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date: Source: Amount: Date:

I am an: Early Career Investigator Established Investigator

Keywords (enter 5-8):         Summary of Project: ( characters) How will this research meet CURE’s mission (no seizures/no side effects), and specifically one of the following priority areas: (1) the basic mechanisms of epileptogenesis; (2) the multifaceted causes of epilepsy; (3) the pediatric epilepsy syndromes; (4) new animal models of epilepsy: ( characters) Research Plan: ( characters) Must include: Hypothesis, Specific Aims, Description of the Research (include brief but succinct detail) Describe how your project will be multidisciplinary. Also, how will collaboration in this project lead to new advances and potential improvements?

Estimated Budget:

Additional Comments:

Have you ever applied for a grant from CURE? Y N Have you ever received a grant from CURE? Y N

How did you hear about CURE:

Do not include materials other than those requested. Additional materials will not be considered in the LOI review process. All materials must be submitted in English.