Application
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(A)
(I) Personal Details of Applicant
Name:……………………………………………………..
Address:……………………………………………………………………………………………
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Phone:…………………………
Fax: ……………………
Email address:…………………………………………….
Date of Birth:…………………………………………….
Sex (M/F):………………………………………………..
Country of Birth:………..………………………………..
Nationality:…………………………….………………….
Educational Background and Training
Institution Year Qualification gained
(II) Representative from
Institution/Company
Name and Address of Institution:………………………………………………………………………
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Phone……………………..
Fax………………………..
Email……………………………………………………………
Brief details of the institution and provide supporting
letter to the research by the institute
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(B)
(I)
Research Details
1. Purpose of research
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2. Reasons to undertake the research
in Vanuatu
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3. The benefits of the research
to the person/Institution/company undertaking the research
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4. The benefits of the research
to Vanuatu.
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5.
Other research team members:
Name Title/Profession Contact
Address Phone/fax/email
6. List of equipment and materials to be used
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7. Length of time to conduct the
research while in Vanuatu
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8. Island (s) intended to conduct
the research on
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9. Describe arrangements made
with your collaborators to undertake the research …………………………………………………………………………………………
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If
the research is supported by donor funding: specify
funding support to the
research and attached to this application the research
proposal for funding.
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I agree that:
Ø This work shall take place in accord with the
laws, policies and procedures of the Republic of Vanuatu.
Ø A copy of all reports and publications stemming
from this work will be lodged in Vanuatu with:………………………………………………………
Ø No samples will be collected without full informed
consent of the owners or providers of the resource from
which samples are collected.
Ø If samples or collections from this work are
to be used for any purpose other than specified in B1
above, the Department will be advised in advance, and
full effort made to obtain prior informed consent from
the owners or providers of the samples.
Signature
of Applicant:………. …………………………………
Date:…………………………..
For
official use only
Approval for the above statement:……………………………
Date:…………………………..
(HEAD of Department)
Department……………………………………………………..
Address:…………………………………………………………
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