EAES Fellowship grant application form

Section 1: Personal details

Please do NOT use ALL capital letters when filling in below information

Title

First name

Last name

Home address (private address)

Postcode + city

Country

Citizenship

E-mail address

Languages spoken

Nationality

Date of birth: Year / Month / Day

EAES member

Yes
No

Your EAES ID number

Section 2: Professional qualifications

University awarding medical degree

Address University

Date of graduation: Year / Month / Day

Are you a resident or surgeon?

Resident
Surgeon

Fill out this part if you are a RESIDENT

Years of postgraduate training

Expected completion of training date: Year / Month /Day

Hospital name

Hospital address

Fill out this part if you are a SURGEON

Date of certification in general surgery: Year / Moth / Day

Board of certification

Current position

Address

Section 3: Host institution for 3 months fellowship

Please select only 3 institutions (1 being your first choice, 2 the second and 3 being your 3rd choice of pereference)

IRCCS, Univ. of Milan, Italy	MCSC, Moscow, Russian Federation
Ponderas Bucharest, Romania	Westchester MC, New York, USA
Kepler University, Linz, Austria	Liv Hospital Ankara & Istanbul, Turkey
Virgen del Rocio, Sevilla, Spain

To view the host institutions facilities description for details being offered and possible restrictions click on the link

First choice

Second choice

Third choice

Section 4: Required documents

Please submit your application including these 5 required documents:

This applies to each required section:
if you have more than 1 document, save them as 1 complete file for upload.

(only submit .pdf, .jpg, Word, jpeg, .tiff, .png files). Maximum is 10mb upload.

Copy of diplomas (M.D., PhD., F.E.B.S./MIS)

CV in English (including the list of presentations & PubMed listed publications)

Letter of motivation (why you want the fellowship grant)

Letter of recommendation (from the Head of department on the official letterhead of the hospital)

A signed letter from your head of department or chief, confirming that you will be allowed to participate in the fellowship program for 3 months.

Additional information

Have you been a faculty in an EAES endorsed workshop(s)?