ESGE MEDTRONIC AI RESEARCH AWARD APPLICATION ESGE MEDTRONIC AI RESEARCH AWARD APPLICATION Personal DetailsTitle*Select a titleDrProfessorName* First name Last name Qualification*Female / Male / Neutral*FemaleMaleNeutralDate of Birth* Date Format: DD slash MM slash YYYY ESGE membership ID*Place of Employment*Community hospitalAcademic hospitalOther (if other, please specify)Please specify other 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Telephone*Email* Enter Email Confirm Email Application informationFull title*Short title*Background of research idea/project (150 words)*Research questions / hypothesis (150 words)**Design / Methods (200 words)**Primary Endpoints (100 words)**Secondary Endpoints (100 words)**Current status of the project (100 words)**Documentation (upload)1. CV of the principal investigators*Please include the CV of the principal investigators in electronic form (one file with CVs of all principal investigators involved, maximum 2 pages each, PDF format, maximum file size: 2 Mb)Accepted file types: pdf.2. Abstract*Please include the abstract including the study title, names of participating investigators with institutions, summary of the proposal (maximum 400 words, PDF format, maximum file size: 2 Mb) Accepted file types: pdf.3. Proposal of the research project*Please include the proposal with aims and hypothesis. This document should also contain all references, images, tables, and illustrations (PDF format, maximum file size: 2 Mb)Accepted file types: pdf.4. Budget*Please include a detailed budget in Euros. Please note that only direct costs may be funded (MS Word, Excel or pdf format, maximum file size: 2Mb) Accepted file types: pdf.Be sure to choose the documents to be attached before submitting this form. 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 mi@hamilton-services.deTerms and ConditionsESGE Privacy Policy* I have read the ESGE Privacy Policy and agree to the terms & conditions.ESGE Medtronic AI Research Award* I have read the ESGE Medtronic AI Research Award terms and conditions and agree to them.Acceptance of ESGE regulations* Entry implies acceptance of these regulations, and all applicants agree to be bound by them upon submitting an applicationPlease fill in all fields marked (*).NameThis field is for validation purposes and should be left unchanged.
