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  <div class="cstlDefaultStyle cstl1" style="font-weight: bold; font-size: 14pt; font-family: Times New Roman; position: relative; font-style: italic; text-align: center;">
   &nbsp;
   <span style="font-family:Arial;font-size:11pt;font-style:normal;">Northern Adelaide Local Health Network</span>
   <span style="font-family:Arial;font-size:11pt;font-style:normal;text-decoration:none;"> <br /></span>
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   <span style="font-family:Arial;font-size:11pt;font-weight:bold;">APPLICATIONS FOR RESEARCH FUNDING </span>
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   <span style="font-family:Arial;font-size:11pt;font-weight:bold;">COVERSHEET AND CHECKLIST</span>
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   <span style="font-family:Arial;font-size:9pt;">Applications for research funding that are being submitted by chief investigators employed in any capacity by the Northern Adelaide Local Health Network (NALHN) must be submitted through the Research Secretariat. Each application must be accompanied by a completed coversheet.</span>
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   <span style="font-family:Arial;font-size:9pt;">The grant application and cover sheet are to be provided to the relevant Head of Department(s) and Divisional Director(s), for signature, </span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">five working days</span>
   <span style="font-family:Arial;font-size:9pt;">&nbsp;before the internal closing date for the application. </span>
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   <span style="font-family:Arial;font-weight:bold;">EACH APPLICATION SUBMITTED MUST BE ACCOMPANIED BY ONE COPY OF THIS COVERSHEET AND ONE COPY OF THE PROPOSED BUDGET </span>
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   <span style="font-family:Arial;font-weight:bold;">TITLE OF PROPOSAL:      </span>
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       <span style="font-family:Arial;color:#ffffff;font-weight:bold;">1</span>
       <span style="font-family:Arial;color:#ffffff;font-size: 60%;font-weight:bold;position:relative;top:-0.5em;">st</span>
       <span style="font-family:Arial;color:#ffffff;font-weight:bold;">&nbsp;NAMED CHIEF INVESTIGATORS - DETAILS</span>
       <span style="font-family:Arial;color:#ffffff;">&nbsp;</span>
       <span style="font-family:Arial;color:#ffffff;font-style:italic;">Please indicate any clinical or title affiliations with SA universities</span>
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       <span style="font-family:Arial;">1 </span>
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     <td colspan="6" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 501.35pt; "> <a name="bm_Text4"></a>
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Title / First name / Surname:</span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
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       <span style="font-family:Arial;">      </span>
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Telephone: </span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;font-style:italic;text-decoration:none;"> <br /></span>
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Mobile: </span>
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Affiliation:</span>
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Department:</span>
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       <span style="font-family:Arial;">      </span>
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     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom:solid 1px #000000;border-right-color:#000000;border-right-style:solid;border-bottom:solid 1px #000000;border-right:solid 1px #000000;width: 140.85pt; "> 
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       <span style="font-family:Arial;font-weight:bold;font-style:italic;">Division:</span>
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       <span style="font-family:Arial;">      </span>
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       <span style="font-family:Arial;color:#ffffff;font-weight:bold;">Other CI’s (2-4) </span>
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       <span style="font-family:Arial;">&nbsp;</span>
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       <span style="font-family:Arial;font-weight:bold;">Title </span>
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       <span style="font-family:Arial;font-weight:bold;">Initial</span>
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     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 127.55pt; "> 
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       <span style="font-family:Arial;font-weight:bold;">Surname</span>
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     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 198.45pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Department / Division</span>
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     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 83.20pt; "> 
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       <span style="font-family:Arial;font-weight:bold;">Telephone</span>
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       <span style="font-family:Arial;">2 </span>
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       <span style="font-family:Arial;">      </span>
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     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 49.65pt; "> 
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       <span style="font-family:Arial;">      </span>
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     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 127.55pt; "> 
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       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-style:italic;">&nbsp;</span>
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     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 198.45pt; "> 
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       <span style="font-family:Arial;">     </span>
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       <span style="font-family:Arial;font-style:italic;">Affiliation:</span>
       <span style="font-family:Arial;">&nbsp;      </span>
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     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 83.20pt; "> 
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       <span style="font-family:Arial;">      </span>
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       <span style="font-family:Arial;">3 </span>
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       <span style="font-family:Arial;">     </span>
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       <span style="font-family:Arial;">      </span>
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       <span style="font-family:Arial;">     </span>
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      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-style:italic;">Affiliation:</span>
       <span style="font-family:Arial;">&nbsp;      </span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 83.20pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">      </span>
      </div> </td> 
    </tr> 
    <tr style=" height:27.60pt; "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 19.60pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">4 </span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 42.50pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-style:italic;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 49.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">      </span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 127.55pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">      </span>
      </div> </td> 
     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 198.45pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-style:italic;">&nbsp;</span>
       <span style="font-family:Arial;font-style:italic;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-style:italic;">Affiliation:</span>
       <span style="font-family:Arial;">&nbsp;      </span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 83.20pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">      </span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;text-decoration:none;"> <br /></span>
  </div> 
  <table cellspacing="0" style="width: 521.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 239.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">FUNDING AGENCY:</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 281.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Name of Funding Scheme: </span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;border-right:solid 1px #000000;width: 521.05pt; "> <a name="bm_Check7"></a><a name="bm_Check8"></a><a name="bm_Check9"></a><a name="bm_Check10"></a><a name="bm_Check11"></a><a name="bm_Check12"></a>
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">App Type: ☐ Project &nbsp;&nbsp;&nbsp;☐Fellowship &nbsp;&nbsp;&nbsp;&nbsp;☐Travel &nbsp;&nbsp;&nbsp;&nbsp;☐Equipment &nbsp;&nbsp;&nbsp;&nbsp;☐Grant Continuation &nbsp;&nbsp;&nbsp;&nbsp;☐Other:</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;text-decoration:none;"> <br /></span>
  </div> 
  <table cellspacing="0" style="width: 522.80pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 76.30pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">AMOUNT REQUESTED</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 74.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Year 1</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 74.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Year 2</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 74.45pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Year 3</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 74.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Year 4</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 74.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">Year 5</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 74.45pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">TOTAL</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:center;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">$</span>
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;text-decoration:none;"> <br /></span>
  </div> 
  <table cellspacing="0" style="width: auto; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#ffffff;border-left:solid 1px #000000;width: 288.90pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Have you attached a copy of your budget: &nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#ffffff;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-transform: uppercase;">Yes &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">&nbsp;☐ </span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 288.90pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">If funded, expected date of commencement:   /  /     </span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Expected date of completion:&nbsp;&nbsp;&nbsp;  /  /     </span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;border-right:solid 1px #000000;width: 521pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">COMMERCIALISATION &amp; INTELLECTUAL PROPERTY</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">Is there the possibility that commercialisation issues will come out of this research? </span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;☐ </span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;color:#ff0000;font-size:8pt;">For Intellectual Property or confidential material matters please refer to the Research Secretariat.</span>
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-weight:bold;text-decoration:none;"> <br /></span>
  </div> 
  <table cellspacing="0" style="width: auto; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" "> 
     <td colspan="5" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;border-right:solid 1px #000000;width: 521pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">ETHICAL/SAFETY CLEARANCES </span>
       <span style="font-family:Arial;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td colspan="5" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;border-right:solid 1px #000000;width: 521pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">Please note:</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;It is the responsibility of the chief investigator to provide notification of clearances to the Research Secretariat. Commencing research activity without the appropriate clearance is a breach of organisational policy and regulatory requirements and can result in significant disciplinary action. </span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">If the attached application has a different title from that which is on the ethical/safety clearance, you MUST provide a statement to the relevant committee stating that the protocol is identical and requesting that the new title be added. Approval for your project has not been granted until written confirmation is received from the relevant committee. </span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 104.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">Approval required</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">Approval attached</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;">Approval number</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" height:30.60pt; "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 104.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Animal Ethics Committee</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no approval, has appln been submitted: Yes/No</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no, when will you submit:</span>
       <span style="font-family:Arial;">&nbsp;  /  /    </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 104.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Human Research Ethics Committee</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no approval, has appln been submitted: Yes/No</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no, when will you submit:</span>
       <span style="font-family:Arial;">&nbsp;  /  /    </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 104.65pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">Institutional Biosafety Committee</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 56.70pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ </span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">Yes</span>
       <span style="font-family:Arial;font-size:8pt;">&nbsp;</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;">☐ &nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;text-transform: uppercase;">No</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 70.85pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">     </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 232.10pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no approval, has appln been submitted: Yes/No</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">If no, when will you submit:</span>
       <span style="font-family:Arial;">&nbsp;  /  /    </span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;text-decoration:none;"> <br /></span>
  </div> 
  <table cellspacing="0" style="width: 521pt; margin-left: 0pt; writing-mode:lr-tb;"> 
   <tbody>
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 521pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:14pt;font-weight:bold;font-style:italic;">Certification by Chief Investigator:</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">I accept responsibility for the performance of the study in compliance with all occupational health safety &amp; welfare and regulatory requirements governing the use of the facilities utilised.</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">I will provide a revised budget to my Head &nbsp;of Unit and Divisional Head(s) if the application is successful but receives less than the funding requested.</span>
       <span style="font-family:Arial;font-size:9pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">I have discussed the research with </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">ALL</span>
       <span style="font-family:Arial;font-size:9pt;">&nbsp;NALHN Heads of Unit whose areas will be involved in any way in the project (including the other investigators) to ensure they are aware of what is involved and approve the project being undertaken.</span>
       <span style="font-family:Arial;font-size:9pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: 510.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:21.55pt; "> 
         <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 212.40pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="5" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 297.65pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Title / First name / Surname</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Unit / Division </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
      </div> 
      <table cellspacing="0" style="width: auto; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:16.75pt; "> 
         <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 251.75pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 123.65pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Signature</span>
       <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Date</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
    <tr style=" "> 
     <td style=" border-top-color:#000000;border-left-color:#000000;border-bottom-color:#000000;border-right-color:#000000;width: 521pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:14pt;font-weight:bold;font-style:italic;">Certification by Head of Unit and Divisional Director:</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">I certify that the appropriate space and general facilities etc. will be available to the applicant if successful and that I am prepared to have the research carried out strictly in accordance with the funding source’s conditions governing the Research Grant at the time. </span>
       <span style="font-family:Arial;font-size:9pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">Is the project viable in terms of the Unit’s and Division’s resources and the funds requested? &nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-weight:bold;">Yes / No</span>
       <span style="font-family:Arial;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: 510.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:21.55pt; "> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 205.30pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="5" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 304.75pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Head of Unit </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Title / First name / Surname</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Unit</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: 510.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:21.55pt; "> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 205.30pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="5" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 304.75pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;">     </span>
           <span style="font-family:Arial;text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Divisional Director </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Title / First name / Surname</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Division </span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: 510.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:13.25pt; "> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 205.30pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 70.90pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="2" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;width: 163pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 70.85pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Signature Head of Unit &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Date&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;Signature of Divisional Director &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Date</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:14pt;font-weight:bold;font-style:italic;">Certification by NALHN Nominee of Administering Institution:</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;">I certify that this request satisfies the requirements of this Institution, and that this Institution has established administrative processes for assuring sound scientific practice in accordance with Australian Code for the Responsible Conduct of Research.</span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: 510.05pt; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:21.55pt; "> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 205.30pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;font-weight:bold;text-decoration:none;"> <br /></span>
          </div> </td> 
         <td colspan="3" style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 304.75pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
           <span style="font-family:Arial;font-weight:bold;">Executive Director, Medical Services</span>
           <span style="font-family:Arial;font-weight:bold;text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Title / First name / Surname</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Position</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;</span>
       <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;font-size:8pt;font-weight:bold;text-decoration:none;"> <br /></span>
      </div> 
      <table cellspacing="0" style="width: auto; margin-left: 0pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
       <tbody>
        <tr style=" height:24.75pt; "> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 251.75pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
         <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 123.65pt; "> 
          <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
           <span style="text-decoration:none;"> <br /></span>
          </div> </td> 
        </tr> 
       </tbody>
      </table> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Date</span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;text-decoration:none;"> <br /></span>
  </div> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
   &nbsp; 
   <hr size="0.0666667px" width="0.0666667px" align="center" color="#a0a0a0" background-color="#a0a0a0" /> 
  </div> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-weight:bold;font-style:italic;">Noted by WCHN Research Secretariat:</span>
  </div> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: auto; margin-left: 5.40pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" height:19.60pt; "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 199.90pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 310.40pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-bottom:0pt;padding-top:0pt;">
       <span style="font-family:Arial;">&nbsp;</span>
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Title / First name / Surname</span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;font-style:italic;">Position</span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
  </div> 
  <table cellspacing="0" style="width: auto; margin-left: 5.40pt; writing-mode:lr-tb;border-top:solid 1px #000000;border-left:solid 1px #000000;border-bottom:solid 1px #000000;border-right:solid 1px #000000;"> 
   <tbody>
    <tr style=" height:24.75pt; "> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-left:solid 1px #000000;width: 255.15pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       <span style="text-decoration:none;"> <br /></span>
      </div> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       &nbsp;
      </div> </td> 
     <td style=" border-top-color:#000000;border-top-style:solid;border-left-color:#000000;border-left-style:solid;border-bottom-color:#000000;border-bottom-style:solid;border-right-color:#000000;border-right-style:solid;border-right:solid 1px #000000;width: 120.50pt; "> 
      <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;padding-left:-36pt;text-indent:0pt;padding-bottom:0pt;padding-top:0pt;">
       &nbsp;
      </div> </td> 
    </tr> 
   </tbody>
  </table> 
  <div class="cstlDefaultStyle cstl0" style=" position: relative; text-align:left;">
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Signature</span>
   <span style="font-family:Arial;">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</span>
   <span style="font-family:Arial;font-size:9pt;font-weight:bold;">Date Received</span>
   <span style="font-family:Arial;text-decoration:none;"> <br /></span>
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