EAES Fellowship Application Form Section 1: Personal Details Name EAES member: Yes No Private Address E-mail address Citizenship Languages Spoken Date of birth: Nationality: d d m m y y Section 2: Professional Qualifications University awarding medical degree Address Date of Graduation d d m m y y Surgeon: Yes No Date of Certification in general surgery: Board of Certification Resident: Yes No Year of postgraduate training Expected completion of training date Hospital Name Address d d m m y y d d m m y y Current position Address Section 3: Host Institution for 3 month Fellowship Please select three institutions writing 1, 2, 3 according to your preference (mark your first choice with 1). University of Torino, Italy VUMC Amsterdam, Netherlands Hospital Clinic Barcelona, Spain University of Pavia, Italy Hospital Santpau Barcelona, Spain MCSC, Moscow, Russian Federation IRCCS, University of Milan, Italy Assuta Tel Aviv, Israel Westchester MC, New York, USA Ponderas Bucharest, Romania Radboud UMC Nijmegen, Netherlands Liv Hosp. Ankara & Istanbul, Turkey Kepler University, Linz, Austria IRCAD-IHU Strasbourg, France Oslo University Hospital, Norway Virgen del Rocio, Sevilla, Spain Saint-Pierre, Brussels, Belgium Please refer to the host institutions facilities description for details of the fellowships offered & possible restrictions! Section 4: Checklist Please ensure the following documents are supplied with the application form: Copy of diplomas (MD., PhD., F.E.B.S./MIS) CV in English (including the list of presentations & PubMed listed publications) Letter of motivation Letter of recommendation (from the Head of Department)