ESGE research endorsement application ESGE research endorsement application "*" indicates required fields Please complete the following application form completely and submit by clicking below on the button "Submit application".Personal DetailsName* First name Last name Qualification* Female / Male / Neutral* Female Male Neutral Date of Birth* DD slash MM slash YYYY ESGE membership ID* Place of Employment* Type of Institution* Contact Address* Street Address Address Line 2 City ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone*Email* Enter Email Confirm Email Application informationFull title*Short title* Research topics (Please select):* Upper GI Colon Small bowel ERCP EUS Other Information for the ESGE website and ESGE Newsletter if your application receives ESGE EndorsementSynopsis of the project (max 100 words)*Link to the website of the study if available Registration number of the study if available Comercial biasIs this an investigator led research project?* Yes No Is this an industry research project?* Yes No If it is an industry led research project, please provide more details by responding to the two following questions.1) What role has industry played in the design of the project?After selecting one or ore options, please specify in a respective text box that will appear below Design Funding Providing free equipement Other Design - Please specify (50 words)Funding - Please specify (50 words)Free equipment - Please specify (50 words)Other (80 words)2) Do funders have any control in publication of the results of this study? Please specify (50 words)Multicentre trialsAre you seeking help from ESGE to encourage new / more centers to participate in your trial?* Yes No If you are seeking centers to participate in multicentre trials, please provide the contact name and Email for participation request.Contact name for participation request Contact Email for participation request Enter Email Confirm Email Endoscopy research ideaBackground (150 words)*Hypothesis / Research Question (150 words)*Methods / Design (200 words)*Measurable end points (200 words)*How will ESGE Endorsement enhance your research? (100 words)*Supporting material (upload)Large files (greater than 8Mb in size) Should your supporting files be larger than the 8Mb limit, please send them via a cost-free online file transfer service such as wetransfer.com to Maria Izquierdo at research@esge.comCV of the principal investigator*Please include the CV of the principal investigator in electronic form (PDF format, maximum file size: 2 Mb) Accepted file types: pdf, Max. file size: 2 MB.Full protocol of the research project*Please include the full protocol of the research project in electronic form (PDF format, maximum file size: 5 Mb) Accepted file types: pdf, Max. file size: 5 MB.If you are planning to apply for funding: Please provide detailsIf you already have secured funding: Please provide details:Terms and ConditionsESGE Privacy Policy*ESGE Privacy Policy and agree to the terms & conditions before submitting your application. I have read the ESGE Privacy Policy and agree to the terms & conditions.ESGE Research Endorsement Policy*Please read the ESGE Research Endorsement Policy and agree to the terms & conditions before submitting your application. I have read the ESGE Research Endorsement Policy and agree to the terms & conditions.Untitled Untitled NameThis field is for validation purposes and should be left unchanged.
