2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1

For NanoLSI Use Only
Application Number:
Application Receipt Date: MM/DD/2024

2024 Academic Year Bio-SPMs Collaborative Research,Application and Collaborative Researcher Approval Form
The applicant must prepare the items below and submit them to the person in charge of Bio-SPMs
Collaborative Research at WPI-NanoLSI, Kanazawa University, through the following e-mail address.
E-mail: nanolsi_openf01@ml.kanazawa-u.ac.jp
・Completed Form 1・Curriculum vitae for the principal investigator (applicant) only

(1) Research Project
Title ofthe research project
List approximately five keywords

Keywords□
Project categories(New or continued)

New research projectContinued research project, taken over a previous Bio-SPMs collaborative□research If you check here, fill out the below items. In the case of a new research project, youcan skip the below part.

Title of the previous
research project
Previous research
periodMM/20XX – MM/20XX

Research resultsfrom the previous
collaborative
research(Publications, etc.)

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2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1(2) Principal Investigator (Applicant): Person Responsible for the Research ProjectNameDate of Birth

MM / DD /19YY (XX years old)

GenderMale/Female

Name ofInstitution
Section(Department,AffiliatedDivision, etc.)

Institution

Position
AddressPhone
numberE-mail

XXXX@XXXXX.XXX.XX

Bio-SPM technology theApplicant Wishes to Use□ Atomic
resolution/3D-AFM□

High-speed
AFM

□

□

Yes

□No

□

Yes

□

No

Will you apply for support for transportation andaccommodation expenses to stay at NanoLSI?
NanoLSI Associate* NanoLSI Associates are graduates of the WISE program forNano-Precision Medicine, Science, and Technology, at KU.

□ AFM for Cellmeasurement

SICM(3) Questions Regarding Application Submission
Why do you want to use Bio-SPM technologies in NanoLSI? Please restrict your answer to three lines.

How did you find out about the NanoLSI Bio-SPMs Collaborative Research?
□ Research papers□ Conference presentations□ NanoLSI’s website□ Acquaintance□ Other (Please specify)

Do you wish “Collaborative Research by sending□

samples”?

Yes

□

No

Please note that the “Collaborative Research by sending samples” is limited to cases where visiting
WPI-NanoLSI is difficult due to the COVID-19-related issues.
Have you contacted a NanoLSI faculty member to discuss the feasibility of this research proposal?
*If you wish “Collaborative Research by sending samples”, you are supposed to contact a NanoLSI faculty member before theapplication.
If “yes,” please write the name(s) of the contacted person(s). (Not available for students)

□ Yes

□ No

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2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1(4) Research Project Team (List of Collaborative Partner Researchers)
Please list everyone else who will participate in this research project, including students and postdoctoral
researchers. Please note that NanoLSI faculty members can be omitted.
Collaborative partner researcher:

Institution

Name
1.

AffiliatedPosition

AddressAge

XX years old

GenderMale/Female

Collaborative partner researcher:E-mail:

XXXX@XXXXX.XXX.XX

AffiliatedInstitution

Name
2.

Address

PositionAge

XX years old

GenderMale/Female

Collaborative partner researcher:

XXXX@XXXXX.XXX.XX

AffiliatedInstitution

Name
3.

E-mail:Address

PositionAge

XX years old

GenderMale/Female

E-mail:

XXXX@XXXXX.XXX.XX*Increase fields if more space for additional researchers is necessary.
*Fill the age of the member at the date of submission.
*If you wish “Collaborative Research by sending samples”, you do not need to fill in this field.

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2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1(5) Schedule for Visiting
Name(Example) Jane Smith

Length of Visit and Number of Times

No. of(Tentative Plans Acceptable)

Days

One day x 3 times, one night/two days x 2 times, 3 nights/4 daysx 1 time

11 daysday(s)
day(s)

Total No. of Days

day(s)*Increase fields if more space is needed.
*If you wish “Collaborative Research by sending samples”, you do not need to fill in this field.
*Fill the total number of days you plan to stay at NanoLSI. The total days should be less than 100 days.
*Visit should be completed by the end of March, 2025 unless there are exceptional circumstances.
* Travel expenses cannot be covered for undergraduate students.

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2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1(6) Pledge for Student Accidents
If any unexpected circumstances occur with the students of the collaborative partner researchers(graduate and undergraduate students) at NanoLSI, I will deal with them in good faith.
Position,Department/Division,Affiliated institutionof the student’s
supervisor
Signature
NameDate

MM/DD/2024*Refer to Application Guidelines “3. Others (f).”*Skip this section if no student is participating in the research project team.

(7) Pledge for Submission of this Application
If you agree, check the following boxes.
□□□□

All information provided in this application is accurate to the best of the applicant’s knowledge.
My research project team will carry out experiments safely and not bring dangerous items,
chemicals, biological samples, etc. to NanoLSI.
My research project team will carefully use Bio-SPMs, related instruments, and accompanying
items.
My research project team will not conceal results obtained through this collaborative research
and will open them to the public.
When the results based on this collaborative research are expected to be included in a□manuscript, etc. of research papers, my research project team will discuss co-authorship or
acknowledgement with NanoLSI host researcher and obtain agreement in advance.
When the research papers based on this collaborative research are published, my research□project team will report them to the person in charge of the Bio-SPMs Collaborative Researchand send the copies of the papers as PDF files.

Signature
NameDate

5 / 6MM/DD/2024

2024 Academic Year NanoLSI Bio-SPMs Collaborative Research Form 1(8) Research Project Description
Fill in the following items using text and Figures/Tables while citing references (Up to 2 pages).

(i) Significance, Purpose, and Originality and novelty of the research project(ii) Expected Results and Necessity of using the Bio-SPMs(iii) Research Plans and Methods
If available, give an overview about the status of sample preparations and the preliminary results. Moreover,estimate the number of measurement days.

(iv) Experience on Bio-SPM observations (optional)
If you have experience, mention the name of the microscope you used and give an overview about the results.

[References][1] Author(s), “Title,” Journal, Vol., Page, (Year).
[2] Author(s), “Title,” Journal, Vol., Page, (Year).
[3] Author(s), “Title,” Journal, Vol., Page, (Year).

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