1. EAES Fellowship Application Form
Section 1: Personal Details
Name EAES member: Yes No
Private
Address
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)