PERSONAL DETAILS

Surname

First Name

Qualifications

Qualifications (Institute | Year)

Year and Category of Membership of EACMFS (see Guidance Notes)

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 visitation aims

Provide addendum of approx. 400 words, if necessary

Proposed dates of visit

(should not exceed four weeks)

Estimated expenses, in Euros:

(up to a maximum of 2000€)

a) Travel

b) Subsistence

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

EACMFS CONGRESS

Year/City

Title of abstract

Date of Submission

Number of Accepted Submissions

Type of Presentation:

Oral

Number

Poster

Number

Main aims of Congress attendance

PLANNED VISIT TO UNIVERSITY COLLEGE LONDON HOSPITAL (UCLH)

Nature of specific study/experience in head & 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

Please upload a letter of confirmation of support from Head of Department of present post/appointment and confirmation that a salary will continue to be paid during the period 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)

Please upload a letter of support for the application with reference to applicants training and abilities

Copy of Abstract submitted to Congress Organisation

If necessary to send more than one file, please zip them and send only the zipped file

Copy of Abstract acceptance notice from Congress Organisation

If necessary to send more than one file, please zip them and send only the zipped file

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 full CV

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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