The American Parkinson Disease Association, Inc.

Fellowship/Research Grant Application

Investigator:

Sponsoring Organization :

Name :
Address :
City :
State :
Zip :
Is Organization Tax Exempt?	Yes No
(Please submit a copy of tax exempt ruling with the original copy of the application.)
Sponsoring Dept :
* Signature of Dept. Chairman :

Human Subject Involved? Yes No

If Yes, was the study protocol approved by the committee on human experimentation? Yes No

Laboratory animals involved? Yes No

If Yes, was the study protocol approved by the committee on laboratory animal experimentation? Yes No

Funding Status:

Is the study being funded at present? Yes No

If Yes, Name of the Organization Amount of funding Duration

Is or was funding applied or committed from elsewhere? Yes No

If Yes, Name of the Organization Amount of funding Duration

Name & title of Grants Office Official :
Signature of Investigator :
* Signature & title of Grant Office Official :
Upload proposal file :
(* Please submit signatures with the original application)