“QANCOR” CARDIOVASCULAR MEDICAL CENTER
APPLICATION FOR FELLOWSHIP
A. Background data concerning the candidate
Family name (surname)
First and middle name
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Permanent address
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Nationality
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Occupation: study, work,
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Telephone……………………………………
E-mail…………………………………………..
Please attach photo here
Mailing address…………………………………………
(if different
from above)………………………………………………..
Telephone……………………………………
E-mail…………………………………………..
Date of birth
day month year
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Country and place of birth
Sex
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Marital status
Number and age of children
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Name and address of person to notify in case of
accident
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Education
Years attended
Name, place and country of educational
establishments
from
to
Secondary, technical, etc.
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Degrees, diplomas: Indicate main subjects
Date
obtained
Post-secondary, university, or equivalent
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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
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Not
easily
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Understand
(spoken)
Not
Easily
easily
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References
List supervisors of any institutes, who can give your characteristics
Speak
Fluently
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Not
fluently
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Write
Easily
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Not
easily
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Previous professional activities
Employer
Dates of service
From
To
Responsibilities
Present position
Current duties
Name and address of employer
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Years of service
From
To
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Exact title of post
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Name and title of supervisor
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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)
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