Embassy of Canada to Italy		Canada-Italy Innovation Award 2014
Public Affairs and Advocacy		www.canada.it

Canada-Italy Innovation Award 2014

Application Form

Please answer all items thoroughly and succinctly. This form is to be filled out by the Canada-Italy Innovation Award applicant, but portions of the form must also be filled out by the Canadian host (sections II and IV). 
Please fill out this form, save it as a PDF and return by email to: Rome-PA@international.gc.ca

I. Applicant Details & Information
Name: 
Position: 
Department:
Name of Dept. Head:
Institution:	
Address:	
Telephone: 
email:	
Name of research group leader (if different):
Group / Institution size (number of members):
Group / Institution website:

1)	How long have you been in your current position?

2)	Please describe the current areas of specialisation of your group / institution (150 words max)

II. Host Details & Information
Name: 	
Position:	
Department:	
Name of Dept. Head:	
Institution:	
Address:
Telephone:		
email:	

Group / Institution size (number of members):	
Group / Institution website:	

3)	How long have you been in your current position?

4)	Please describe the current areas of specialisation of your group / institution (150 words max)

III. Collaboration Details
5)	Describe your proposed project in 140 characters
6)	Provide a brief overview of the proposed collaboration (100 words max)
7)	Proposed start date of travel:
8)	Duration of visit:
9)	Have the applicant and host’s groups previously collaborated?  If yes, please describe the subject and duration of the collaboration and identify if it is ongoing (100 words max)
10)	List the activities that will be carried out during the visit.  Is it anticipated that the applicant will give a lecture/seminar at the host’s institution? What complementary skill sets or technologies will be brought together?  What is the strategic advantage of this partnership and why is it important that this be an international collaboration?  If this is an ongoing collaboration, please also identify how this opportunity will enable the participants to broaden the collaboration or expand it in a new direction (500 words max)
11)	What are the long-term goals for this collaboration and the expected outcomes over the next 6-12 months?  What joint activities (with timeline) do you anticipate will need to occur after the visit to deliver these results?  Is there potential to broaden this collaboration over time? (300 words max)

IV. Host’s Invitation
This section is to be filled out by the Canadian host. Please provide a statement of intent for the applicant’s visit to your site (500 words max)

When complete, the host should type his or her full name below. This will serve as his or her electronic signature.
I, the host, confirm that the information that I have given is true and complete.
Signature:	Date: 

V. Expenses 
12)	 Please estimate the costs to be incurred during your visit in Euros.
International travel (airfare only): € 
Accommodation: € 
Local Transportation: € 
Per diem (flat rate/day € 60): € 
Total (maximum €3,000): € 
Please note that the Canada-Italy Innovation Award only provides funding for economy class air travel, accommodation, local transport and per diem up to a maximum of €3,000. Furthermore, funding is to be used for the applicant only, and cannot be used for the applicant’s spouse or family members.
Authorisation
I, the applicant, confirm that the information that I have given is true and complete.
Signature:	Date: 

Please type in your full name. This will serve as your electronic signature.
Submitting this application
Please send to Rome-PA@international.gc.ca:
	• Completed application, including sections completed by the host, saved in PDF format
	• Applicant’s CV (2 pages max)
Please write “Canada-Italy Innovation Award” in the subject line of your message.
Applications and supporting materials are due by April 1, 2014 (11:59pm Rome time)