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növüApplication form


Form 1 (for Articles No. 4 & No. 6)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.
(Address)
(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)


Grant Application Form for “Yamada Research Grant 2013”
I apply for the provisioning of the grant mentioned above in the title by following Article No. 6 in the “Yamada Research Grant 2013” Outline for Grant Provision as follows. I will implement a research for the following research theme based on the separately submitted research plan document, and will make a report of the research outcomes by the due date specified by the Yamada Bee Company, Inc.
Description
1 The theme of the grant research 

(English)                                  
2 The overview and the purpose of the grant research (explain in an easy to understand description, in approx. 240 characters)

3 The amount applied for the grant:

             Yen (Japanese yen)


4 The concrete contents, etc. of the grant research, and the allocation of expenses required for the grant research

 As specified in (Exhibit) Grant research Plan Document for “Yamada Research Grant 2013”.


5 Research period: year(s)

6 The research period scheduled end date: September 30, 20 .



(Exhibit of Form 1) Grant research Plan Document for “Yamada Research Grant 2013”
1 Contents of the research, etc.

Ⅰ. Outline of the research

・Outline of the research and the targeted outcome
Outline:

Impact of the outcome:



2 Research Plan






Research Design

※Please fill out this column with the necessary information below.

・object

・sample size



・the extent of exposure

(methods of administration, dose, dosage schedule)

・end point


Necessary Equipments and Materials

※ Please fill out this column with the necessary information as described in Appendix of the Outline for Grant Provision.



Amount
(Yen)

Expenses category
(number)

(period)

 

 




 

 

 

 




 

(year/month)

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 

 

 




 

 







 




Total

 

 Yen

(Japanese yen)



※ As for the expenses category number, please refer to Appendix of “Yamada Research Grant 2013” Outline for Grant Provision

(There is not a limit on number of pages. Please add lines as necessary.)




Ⅱ.Joint research partners

(Fill in the following columns when you plan to implement joint researches. If there are several partners, make sure to describe all of them.)



Institutional Affiliate




Co-researchers




Address

〒   -

Contents of

allocated researches, etc.





Equipments /

facilities / building

possessed by the

partner







Ⅲ.Consignee / Subcontractor

(Fill in the following columns when you plan to consign / outsource a part of your research. If there are several consignees / subcontractors, make sure to describe all of them.)



Institutional Affiliate




Address

〒   -

Contents of consignment / outsourced works, etc.




Equipments / facilities / building possessed by the consignee / subcontractor







Ⅳ. Technical guidance or cooperation to be gained from other parties (Fill in the following columns when you plan to have technical guidance or cooperation provided.)

Institutional Affiliate




Name of instructor / cooperating person




Title




The matter for which the guidance or cooperation will be provided







Ⅴ.Samples to be provided (Fill out the columns with amount required and reasons about the sample(s) required for your research. See 'Research samples of honeybee products and natural products' page on our website for more details on each sample.) URL(http://grant.bee-lab.jp/grant/grant_2013/sample.html)

・Samples for clinical trials



Samples

Amount required

Reasons (administration route, amount of intake, research period, number of subjects, etc.)

Enzyme-treated royal jelly [100 coat tablets / bottle]

bottle




Placebo (for Enzyme-treated royal jelly) [100 coat tablets / bottle]

bottle




Brazilian propolis [100 softgel capsules / bottle]

bottle




Placebo (for Brazilian propolis) [100 softgel capsules / bottle]

bottle




Enzyme-treated bee larvae [100 softgel capsules / bottle]

bottle




Placebo (for Enzyme-treated bee larvae) [100 softgel capsules / bottle]

bottle




Acacia honey [300 g / bottle]

bottle




Bee pollen (no placebo) [120 plain tablets / bottle]

bottle




Melinjo resveratrol [62 capsules / pouch]

pouch




Placebo for melinjo resveratrol [62 capsules / pouch]

pouch




Glucosamine [120 capsules/pouch]

pouch




Collagen [300 plain tablets/ pouch]

pouch




Bilberry [60 capsules/ pouch]

pouch




DHA/EPA [150 softgel capsules/ pouch]

pouch




Sesamin [60 plain tablets/ pouch]

pouch




Chlorella [300 plain tablets/pouch]

pouch




Lutein, Coenzyme Q10, Hyaluronic acid, Ginkgo biloba extract, Chondroitin, Saw palmetto, Maca, Octacosanol, etc. [capsules]

※Please type sample's name, amount and the reason for research samples you want in the "Reasons (administration route, amount of intake, research period, number of subjects, etc.)" column.






・Samples for animal and/or in vitro test



Samples

State

Amount required

Reasons (administration route, research period, number of groups, number of subjects, etc.)

Royal jelly powder (enzyme-treated)

powder

    g




Royal jelly powder (enzyme-untreated)

powder

    g




Ethanol extract of Brazilian propolis

liquid

g




Ethanol extract powder of Brazilian propolis

powder

   g   




Bee larvae powder (enzyme-treated)

powder

    g




Acacia honey

liquid

    g




Bee pollen

powder

g




Extract powder of Melinjo seed

powder

    g




Glucosamine powder

powder

g




Collagen powder

powder

g




Bilberry powder

powder

g




DHA/EPA oil

powder

g




Sesamin powder

powder

g




Chlorella powder

powder

g




Lutein oil, Coenzyme Q10 powder, Hyaluronic acid powder, Ginkgo biloba extract powder, Saw palmetto oil, Chondroitin powder, Maca powder, Octacosanol, etc.

※Please type sample's name, amount and the reason for research samples you want in the "Reasons (administration route, research period, number of groups, number of subjects, etc.)" column.



See the left column









                                       


Form 2 (for Article No. 6)
Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

Promissory Letter

I pledge that as for receiving the “Yamada Research Grant 2013”, that I consent to the contents specified in the “Yamada Research Grant 2013” Outline for Grant Provision and that I will implement the following grant research.

Description
<Contents of the grant research>


The theme of the grant research




Grant amount

           Yen (Japanese yen)

Outline and

purpose of the

grant research



Grant period

October 1, 2013 – September 30, 20

Research method

As described in Grant Application Form for “Yamada Research Grant 2013” (Form 1) and “Research Plan Document” (Exhibit of Form 1).

Name of

co-researchers






Date: (day), (month), (year)

(Address)


(Tel. / Fax)

(Institutional Affiliate)

(Title)

(Print Name)



(Signature)

Form 3 (for Articles No. 6)

Date: (day), (month), (year)
Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.
(Address)
(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Bank Transfer Account Notice for “Yamada Research Grant 2013”

I notify hereafter the account for the “Yamada Research Grant 2013”.


Bank transfer account

 (Account with Institution)



Bank and Branch Name




 Branch Address 




SWIFT Code. FED ABA.




SORT Code. BLZ No.




Country







Account number




Beneficiary Customer




Beneficiary Address

(Country: )






Contact information for the person in charge or account businesses

(Please fill in this column only when the person in charge of the accounting works is different from the applicant.)



(Institutional Affiliate)

(Name)           (Title)

(Tel.)    (Fax)

(Mail)


Credit

                         Yen (Japanese yen)


Form 4 (for Articles No. 11)

Date: (day), (month), (year)
Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Application Form for Changes for the Grant Research (Contents / Expenses Allocation) for “Yamada Research Grant 2013”

I apply for the approval for the changes for the grant research mentioned in the title (contents / expenses allocation) whose grant provisioning notice had been issued as No. as of (date) (month) (year) as described below, by following the provision specified in Paragraph 1 of Article No. 11 of the “Yamada Research Grant 2013” Outline for Grant Provision.


Description
1 Reason for the change

2 Description of the change

3 Impact assumed from the change
(Exhibit of Form 4)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)


        Representative (Organization, Address, Title) Change Notice
 I notice the change or representative (organization, address) as follows.
                  Description
1 Reason for change

2 Changed matter

3 Changed to;
Form 5 (for Articles No. 13)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Grant Research Cancellation (Discontinuation) Approval Application Form for

“Yamada Research Grant 2013”

I apply for the approval for the cancellation (discontinuation) for the grant research mentioned in the title whose grant provisioning notice had been issued as No. as of (date) (month) (year) as described below due to the following reason, by following the provision specified in Article No. 13 of the “Yamada Research Grant 2013” Outline for Grant Provision.
Description
1 Research theme

2 Reason for the cancellation (discontinuation)


3 Cancellation (discontinuation) period
Note) Make sure to attach explanatory documents.
Form 6 (for Articles No. 14)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Report on Delay of the Grant Research, etc. for “Yamada Research Grant 2013”

I report the following accident for the grant research mentioned in the title whose grant provisioning notice had been issued as No. as of (date) (month) (year), by following the provision specified in section Article No. 14 of the “Yamada Research Grant 2013” Outline for Grant Provision.


Description
1 Progress status of the grant research

2 The description and cause of the accident

3 Measures taken for the accident

4 Schedule for implementing / completing the grant research

Note) Make sure to attach documents proving the cause of the accident (in any format).

Form 7 (for Articles No. 13 & No.16)

Date: (day), (month), (year)
Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Final Report for “Yamada Research Grant 2013”

I have completed (cancelled) the grant research mentioned in the title whose grant provisioning notice had been issued as No. as of (date) (month) (year) on (date) (month) (year), and therefore report its outcome hereafter by following the provision specified in Articles No. 13 & No. 16 of the “Yamada Research Grant 2013” Outline for Grant Provision.


Description
1 Research theme    (English)                       
2 The amount received for the grant               Yen (Japanese yen)
3 Outcome of the grant research

  1. Summary (in English within approx. 240 characters)

※ The summary will be posted on the website of Institute of Bee Products and Health Science without making any correction.


  1. Details

 As described in (Exhibit) Grant research Result Report for the “Yamada Research Grant 2013” and in the dissertation for the grant research.

   Note) If there is any reference material for the outcome of the grant research (photographs, result document, etc.), make sure to attach it.

(Exhibit of Form 7) Grant research Result Report for “Yamada Research Grant 2013”


Joint research
(1) Name of organization

(2) Division of roles

(3) Contract day





Consigned research
(1) Consignee/address

(2) Contents of the

research





Guidance, etc. gained from other organizations
(1) Name of organization

(2) Name of the person

(3) Title

(4) Contents of the

guidance, etc.





Form 8 (for Articles No. 13, No. 15, No. 16 & No. 21)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Payment Details for “Yamada Research Grant 2013”


No.

Paid on (date / month / year)

Name or description

Price

Sales tax

Total

Expenses category

(number)


 

 

 

 

 




 

 

 

 

 

 




 

 

 

 

 

 




 

 

 

 

 

 




 














































 

 

 

 

 




 

 

 

 

 

 




 

 

 

 

 

 




 















※As for the expenses category number, please refer to Appendix of the “Yamada Research Grant 2013” Outline for Grant Provision and make sure to list the items in the order corresponding to date of payment.


Form 9 (for Articles No. 15 & No. 16)

Date: (day), (month), (year)


Mr. Hideo Yamada,

President,

Yamada Bee Company, Inc.

(Address)


(Tel. / Fax)

(E-mail)


(Institutional Affiliate)

(Title)


(Print Name)

(Signature)

Interim Report for “Yamada Research Grant 2013”
( year/ years)

Eg. (1st year/3 years)


I report hereafter for the grant research mentioned in the title whose grant provisioning notice had been issued as No. as of (date) (month) (year) as described below by following the provision specified in Article No. 15 & No. 16 of the “Yamada Research Grant 2013” Outline for Grant Provision.
Description
The status of the grant research;

The future plans of the grant research;


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