LTSN Centre for Bioscience
Application for Special Interest Group Co-ordinators

Applications must be made on this form. Please submit one paper copy (signed) and a copy on disc. The form should be returned no later than Friday 22nd November, 2002 to:

Trish Walker, Centre Manager,
LTSN Centre for Bioscience, 
School of Biochemistry and Molecular Biology, 
University of Leeds, Leeds, LS2 9JT.

Tel/Fax: 0113 343 3001, email: ltsnbioscience@leeds.ac.uk
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1. Proposed SIG Title:

	

2. Personal details
Title		
First name		Last name		
Department		
Institution		
Address		

		
		
Telephone		Fax		
Email		

3. Please outline the key aims and outcomes of the SIG and the activities required to achieve them.  What support will you require from LTSN Bioscience?
The text box will expand as you type.

	

4. Please outline how you intend to form and maintain a network of interested colleagues to participate in the activities of the SIG. 
What support will you require from LTSN Bioscience?
The text box will expand as you type.

	

5. Please outline the key dissemination activities/outputs of the SIG. 
What support will you require from LTSN Bioscience?
The text box will expand as you type

	

6. In order to help us assess your application please state your expertise addressing each of the following criteria in turn. Please number each section to correspond with the criteria.
The text box will expand as you type
1)	academic (tertiary) and professional qualifications
2)	teaching experience and current teaching responsibilities
3)	membership of professional bodies
4)	publications in the field of learning and teaching
5)	expertise in the SIG topic of interest
6)	experience of co-ordination and networking
7)	additional information in support of your application 

	

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7. Copyright statement. 
Proposals will be deemed ineligible if this section is incomplete. 
I agree to relinquish copyright on any original material generated so that it may be freely distributed to UK HE and FE institutions	
Signature of proposer:

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8. Departmental authorisation. 
Proposals will be deemed ineligible if this section is incomplete.
I confirm that the proposer has my support in applying to become an LTSN Bioscience Discipline Consultant.	
Name: 

Position:
	
Signature:

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