application form for fellowship
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“QANCOR” CARDIOVASCULAR MEDICAL CENTER APPLICATION FOR FELLOWSHIP A. Background data concerning the candidate Family name (surname) First and middle name ………………………………………………… ………………………………………… Permanent address ………………………………………………………………… Nationality ……………….. Occupation: study, work, ________ ………………. Telephone…………………………………… E-mail………………………………………….. Please attach photo here Mailing address………………………………………… (if different from above)……………………………………………….. Telephone…………………………………… E-mail………………………………………….. Date of birth day month year ……. ………….. ………… Country and place of birth Sex ………………………………………………………………………… …………………. Marital status Number and age of children ………………….. ……………………………………………. Name and address of person to notify in case of accident ……………………………………………………………………… Education Years attended Name, place and country of educational establishments from to Secondary, technical, etc. ………………………………………………………………. ………………………………………………………………. ………………………………………………………………. ……… ……… ……… ……… ……… ……… ……………………………………………………………………….. ……………………………………………………………………….. ……………………………………………………………………….. …………… …………… …………… ………. ………. ………. ………. ………. ………. ………. ………. ………. ………. ……………………………………………………………………….. ……………………………………………………………………….. ……………………………………………………………………….. ……………………………………………………………………….. ……………………………………………………………………….. …………… …………… …………… …………… …………… Degrees, diplomas: Indicate main subjects Date obtained Post-secondary, university, or equivalent ……………………………………………………………… ……………………………………………………………… …………………………………………………………….. ……………………………………………………………… …………………………………………………………….. IMPORTANT: This application is not considered complete unless accompanied by certified copies of diplomas received and academic transcripts of courses followed and grades or marks obtained Other studies Mention any other studies undertaken, including training/refresher courses Visits abroad List any significant visits abroad Publications and research List any significant publications (including date of publication) and any major research projects undertaken Languages Mother tongue: Read Other languages Easily ……………………………………………. ……………………………………………. …………………………………………… ……………. ……………. ……………. Not easily ……………. ……………. ……………. Understand (spoken) Not Easily easily ……………. ……………. ……………. ……………. ……………. ……………. References List supervisors of any institutes, who can give your characteristics Speak Fluently ……………. ……………. ……………. Not fluently ……………. ……………. ……………. Write Easily ……………. ……………. ……………. Not easily ……………. ……………. ……………. Previous professional activities Employer Dates of service From To Responsibilities Present position Current duties Name and address of employer …………………………………………………………………………………….. …………………………………………………………………………………….. Years of service From To ……………………… ……………….. …………… Exact title of post …………………………………………………………………………………….. …………………………………………………………………………………….. Name and title of supervisor …………………………………………………………………………………….. ……………………………………………………………………………………. B. Training objectives Nature of studies Indicate field of study and particular areas of specialization you prefer to apply (Interventional cardiology, Cardiology, Cardiac surgery, Intensive care and anesthesiology) ___ _____ 20 signature _____________________________________
