Submit this form to RIC by the 5pm 31 January 2018. This form must be completed for all CI’s and AI’s as per NHMRC requirements. Electronic signatures are accepted. If any CIs or AIs have provided written evidence via email using the required text, please attach the email to this form. Combine this form as well as any email certifications in one pdf document.

To submit your Final Application to NHMRC:

Certify your application in RGMS – the status should be “Submitted to RAO” and provide an electronic copy of this form to RIC via email to nhmrc-project@unimelb.edu.au by 5pm 31 January 2018.

Application for: (please tick the appropriate funding bodies)

* NHMRC ID Generated by RGMS	APP
* UOM Notice of Intent (NOI) number Submit an NOI at: https://ric-noticeofintent.app.unimelb.edu.au/apex/f?p=ric_noi:noi_form	N
* CIA Name Including title, e.g. Dr, A/Prof., Prof.
* Department and Faculty The Department administering the grant
* CIA mobile phone number In case of problems preventing submission to NHMRC
* CIA email address
* Alternate Contact: Name & phone number In case we are unable to contact CIA for urgent issues

(*) mandatory information

Compliance & Eligibility Checklist Completion & initial for each section on this table is mandatory	Yes	N/A	CIA Initial
CV & Profile sections completed as per scheme requirements (refer to Development Grant Advice & Instructions to Applicants)
RGMS Application: All relevant sections of in RGMS have been completed
All CIs meet the eligibility requirements specified in the NHMRC Development Grant Funding Rules for funding commencing in 2019
Grant Proposal PDF is uploaded in RGMS and complies with formatting requirements
B-PB Proposed Budget – DRC and Equipment Section completed
All CIs and AIs (if relevant) have either signed the Authority to Submit form or provided email confirmation of involvement
The application has been certified in RGMS and status is ‘Submitted to RAO’

Certification by Chief Investigator (CIA)

I have read and understood the NHMRC Development Grants Funding Rules for funding commencing in 2019 and am satisfied that I meet the eligibility criteria as specified;

I have complied with the NHMRC Development Grants Funding Rules for funding commencing in 2019, and NHMRC Advice and Instructions to Applicants; and if the Proposal is successful I agree to abide by the terms of the Funding Agreement relating to NHMRC Development Grants; and

I have identified, disclosed and managed any real or perceived Conflicts of Interest and this Proposal does not contain any plagiarised, fabricated or falsified data or information as per the requirements of the Codes of Conduct for Research (Australian Code and the University of Melbourne code). I undertake that, if the Proposal is successful, I will notify the Administering Organisation of any conflicts of interest which arise subsequent to the submission of the Proposal.

CIA Signature	Date

Certification by Head of Department#/Institute Director#

I agree that the project can be accommodated within the general facilities in my Department/Institute and that sufficient working and office space is available for any proposed additional staff;

I am prepared to have the project carried out in my Department/Institute under the circumstances set out in the proposal; and

I agree that the funding shortfall between the NHMRC salary package and University salaries will be met and a University appointment will be set up if the grant is awarded.

HOD/Director Name#
HOD/Director Signature#	Date

(#) If the CI is the HOD/Director, certification must be obtained by the Dean/CEO

Certification by other CIs (CIB-CIJ)

As per item 7.5 of the NHMRC Funding Rules, written evidence of all CI’s approvals to be named as Chief Investigators on this project is required. Written evidence can be provided by signing below or alternatively as an email. If an email is provided, please attach a copy of the email to this form and ensure it clearly states the below text and the application ID in the body.

I certify that:

I agree to be named as a Chief Investigator on this application and NHMRC providing the application, snapshot reports and information about the results of NHMRC’s assessment of this application to third parties; and

I agree to the final application being certified on my behalf by the CIA.

CI	CI Full Name	Organisation/ Institution Name	Signature of CI	OR	Email confirmation of CI attached to this form (please tick) Do not forward emails to RIC
CIB	OR
CIC	OR
CID	OR
CIE	OR
CIF	OR
CIG	OR
CIH	OR
CII	OR
CIJ	OR

Certification by Associate Investigators (AIs)

As per item 7.5 of the NHMRC Funding Rules, written evidence of all AI’s approvals to be named as Associate Investigators on this project is required. Written evidence can be provided by signing below or alternatively as an email. If an email is provided, please attach a printed copy of the email to this form and ensure it clearly states the below text and the application ID in the body.

I certify that:

i)	I agree to be named as an Associate Investigator on this application; and

ii)	I agree to the final application being certified on my behalf by the CIA.

AI Full Name	Organisation/ Institution Name	Signature of AI	OR	Email confirmation of AI attached to this form (please tick) Do not forward emails to RI&C
OR
OR
OR
OR
OR
OR
OR
OR
OR
OR