PERSONAL DETAILS

Please type or use BLOCK CAPITALS and ensure that ALL sections are completed (Note: incomplete forms will not be considered)

Surname

First Name

Qualifications (Date and Institute)

Date and Category of Membership of EACMFS (see Guidance Notes above)

Present Post/Appointment

Address

Date of Appointment

DETAILS OF CENTRE TO BE VISITED

Name of Hospital/Institute

Head of Department

Nature of study/experience to be gained including aims of the visitation

*Please provide addendum of approx. 400 words

Proposed dates of visit:

(should not exceed four weeks)

Estimated expenses:

(up to a maximum of 2000€)

a) Travel

b) Subsistence

(Proof of expenses with copies of receipts required prior to payment)

EACMFS CONGRESS

Year/Venue

Title of abstract

Date of Submission

Number of Accepted Submissions

Type of Presentation:

Oral

Number

Poster

Number

Main aims of attending the Congress

PLANNED VISIT TO UNIVERSITY COLLEGE LONDON HOSPITAL (UCLH)

Nature of specific study/experience in head and neck oncology anticipated

Proposed dates of visit (should not exceed three months)

Previous links / contacts with UCLH

Estimated expenses:
(in Euros)

a) Travel

b) Subsistence

DOCUMENTARY SUPPORT

Head of Department of present post/appointment

I support this application and confirm that a salary will continue to be paid during the period of leave of absence

Copy of written confirmation/acceptance letter provided by the Head of Department to be visited to be attached

EACMFS Council Member (normally the appropriate National Councillor – contact Secretariat for further details if required)

I am aware of the applicant's training and abilities and support this submission

Copy of Abstract submitted to Congress Organisation

Copy of Abstract acceptance notice from Congress Organisation

Copy of Registration Form for Congress

Copy of Registration payment receipt

Confirmation of eligibility for appropriate registration with the UK General Medical Council
www.gms-uk.org
(copy of certificate/correspondence)

CURRICULUM VITAE

Summary of Curriculum Vitae

(Please include details of previous appointments with dates/ prizes/awards/distinctions etc and publications)

Attach further document

CAREER ASPIRATIONS

Summary of career aspirations (Personal statement)

Attach further document if necessary

AIMS AND OBJECTIVES

Aims, objectives and the gains anticipated by the visitation

Attach further document if necessary

PREVIOUS EACMFS AWARDS/SCHOLARSHIPS

Type

Date

DECLARATION

I agree that if successful in this application I will submit a report to the Secretary-General within three months of returning and that the copyright that the copyright of any paper resulting from the scholarship will rest initially with the Editor-in-Chief of the Journal of Cranio-Maxillo-Facial Surgery

I agree with the terms above

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