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

E-mail address additional

Languages spoken

Nationality

Date of birth

EAES member

Yes
No

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 perference)

Assuta, Tel Aviv-Israel	Oslo University Hospital, Oslow-Norway
Hospital Clinic, Barcelona-Spain	Policlinico San Matteo, Pavia-Italy
Hospital Santpau, Barcelona-Spain	Ponderas Academic Hospital, Bucharest-Romania
IRCAD, Strasbourg-France	Radboud UMC, Nijmegen-The Netherlands
IRCCS University of Milan, Italy	University Hospital Virgen Macarena, Sevilla-Spain
Kepler University Klinik, Linz-Austria	University of Torino, Italy
Bilkent City Hospital/Güven Hospital, Ankara -Turkey	VU Medical Center, Amsterdam-The Netherlands
MCSC, Moscow-Russia Federation	Westchester Medical Center, New York-USA

First choice

Second choice

third choice

Section 4: Required documents

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)?

Yes
No

If yes, please specify when and in which workshop(s)?

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