UNI CONFIRMATION FORM - R&D FELLOW > SEPT 2019 (V1.4)
University Confirmation Form
R&D Fellowship Grant
BUSINESS DETAILS
Business name:
Contact person:
UNIVERSITY DETAILS
Organisation name:
Supervisor name: Telephone:
Email:
Contract liaison name: Telephone:
Email:
STUDENT DETAILS
Full name: Telephone:
Personal Email:
Area of study: Level:
Programme title: Prog. code:
Thesis or project title:
Points for research component of qualification:
Duration of research thesis or project:
Enrolment status*:
* A student must be identified but does not need to be enrolled in a postgraduate programme for a Fellowship application to be
considered and approved for funding. However, evidence of the student’s enrolment must be provided before a funding agreement will
be issued and any funding paid.
Businesses applying for an R&D
Fellowship Grant with Callaghan
Innovation must identify an eligible
student with the assistance of a New
Zealand university (or tertiary
education provider).
Please complete your business details
below and provide this form to your
university contact to complete.
This form will supplement your grant
application. Please upload the signed
form in section 3 of your online
application.
For more information, talk to your
Callaghan Innovation or Regional
Business Partner account manager or
phone us on 0800 4 CALLAGHAN.
Please provide a long term email address so we can survey you in the future
Please select:
Please select:
E.g. Masters of Engineering
E.g. AK1325
E.g. 1 year full time
Please select:
STUDENT DETAILS FORM - R&D
FELLOW
> 2017 (v1)
UNI CONFIRMATION FORM - R&D FELLOW > SEPT 2019 (V1.4)
UNIVERSITY CONFIRMATION
The following sections are to be completed by the research office at the host university (or equivalent) and signed by an
authorised signatory
Confirm research project is relevant to the student’s field of study:
Confirm the research office at the university has been advised of this application:
Confirm that intellectual property arrangements have been agreed with the business:
Confirm the host tertiary education provider understands its health and safety
obligations and will cooperate, coordinate and consult with the business regarding any
overlapping duties:
Confirm the host tertiary education provider has read, and understands, the Callaghan
Innovation Roles & Responsibilities Guidelines:
UNIVERSITY DECLARATION
I declare that, to the best of my knowledge, the information provided in this form is true
and accurate
Full name:
Job title:
Signature:
Date:
click to sign
signature
click to edit
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