2017
Facial fellowship
Application factsheet
Date:
Family name:
First name:
Gender:
Age:
Address:
City:
Country:
Nationality:
Telephone:
Email:
Current hospital:
PLEASE MAKE SURE TO ANSWER ALL QUESTIONS!
Incompletely filled in forms will not be processed! The deadline for submission is 1 May 2016.
I. Specialist trainee
1. Are you in a medical specialist training program?
2. If so, then in what kind of training program are you?
Plastic Surgery
Maxillofacial Surgery
Otolaryngology (ENT)
Other (please specify)
3. When did you start your specialist training program?`
4. What is the duration of this specialist training program in your country?
5. In what year of your training program will you be by 1 January 2017?
I have to do another 2 years
I am in my last year
Other (please specify)
6. On what date are you expected to finish your training?
II. Post graduate
1. Are you a qualified medical specialist in your country?
2. If yes, on what date did you finish your specialist training program?
3. What specialist training program did you finish?
Plastic Surgery
Maxillofacial Surgery
Otolaryngology (ENT)
Other (please specify)
4. What is your predominant work location?
General hospital
Specialised hospital (i.e.oncological or childrens hospital)
Teaching hospital
Medical University hospital
Private clinic
Other (please specify)
III. Preferences
1. Do you (if any) have a preferred fellowship starting date?
No, all possible
January 2016
April 2016
July 2016
October 2016
2. Depending on availability, the fellowship can consists of two parts. In that
case you will be visiting two units for a period of three months each.
Do you prefer a 6 months or a 3 months fellowship?
3. Would you be able to do six months, even if you would have to take a 3
months break in between phase 1 and 2?
Before answering this please be aware of the consequences of European visa
limitations, for which you should check the practical issue page on our website.
4. If a fellowship would become available unexpectedly, would you be willing
and able to fill such a vacancy on short notice (ie within a couple of weeks?)
5. Do you have a preferred location? (more preferences are allowed)
Rotterdam
Ghent
Montreux
London
Stuttgart
Köln
Vienna
San Francisco
Trissur
6. Please specify what field you would like to focus on in this fellowship
(more preferences are allowed):
Congenital craniofacial (craniosynostosis)
Cleft surgery
Oncological reconstructions/microsurgery
Facial reanimation
Rhinoplasty
Aesthetic surgery
Other (please specify)
IV. Training
Please list the dates and functions of the (training) jobs you have had up till now in
chronological order, starting with and working back from your current job:
Current job
Dates
Function
Department
Hospital
Previous job (1)
Dates
Function
Department
Hospital
Previous job (2)
Dates
Function
Department
Hospital
Previous job (3)
Dates
Function
Department
Hospital
Previous job (4)
Dates
Function
Department
Hospital
Previous job (5)
Dates
Function
Department
Hospital
Previous job (6)
Dates
Function
Department
Hospital
Previous job (7)
Dates
Function
Department
Hospital
V. Research
Please list the research you have done to date. Include if any scientific outcome was
achieved (i.e. presentation at conference. If paper published, then give reference):
1.
Subject
Year
Supervisor
Presented?
Where?
If published, please
give reference:
2.
Subject
Year
Supervisor
Presented?
Where?
If published, please
give reference:
3.
Subject
Year
Supervisor
Presented?
Where?
If published, please
give reference:
4.
Subject
Year
Supervisor
Presented?
Where?
If published, please
give reference:
5.
Subject
Year
Supervisor
Presented?
Where?
If published, please
give reference:
VI. Motivation
Please motivate why you wish to join our facial plastic surgery fellowship
programme and why you think we should approve your application?
VII. References
Please name three people who are willing to provide you with a reference. Be
aware that your application will not be processed without these references.
- If you are in a training programme: one of them has to be the training course
director.
- If you are working at a department: one of them has to be your head of
department.
1. Name
Function = Head of training program/Head of department (please specify)
Email
Telephone
2. Name
Function
Email
Telephone
3. Name
Function
Email
Telephone
VIII. How did you find out about this fellowship?
IX. Remarks
Any special remarks you’d like to make?