APPLICATION For 8 WEEKS SCHOLARSHIP or 1 YEAR FELLOWSHIP PROGRAMME IN FACIAL COSMETIC SURGERY

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1 EACMFS PO BOX 85 MIDHURST WEST SUSSEX GU29 9WS UNITED KINGDOM Tel.: Fax: +44 (0) (0) E mail: Http: secretariat@eacmfs.org APPLICATION For 8 WEEKS SCHOLARSHIP or 1 YEAR FELLOWSHIP PROGRAMME IN FACIAL COSMETIC SURGERY INSTRUCTIONS Please read carefully. Medical Graduates who are qualified specialists in maxillofacial surgery and being eligible to pursue an EACMFS Scholarship or Fellowship must contact individual (fellowship) directors of EACMFS accredited training units for specific information on applying to their Scholar- or Fellowship. They may be required to submit additional information (full CV, operative experience list, convincing interest in the chosen surgical subspecialty future plan statement, references). Applicants must be full members for applying for Fellowship (full or trainee for Scholarship) of the EACMFS before applying for such a training programme. This Application form and required attachments should be sent by to the Secretariat Office of the EACMFS at secretariat@eacmfs.org by July 1st of the year before the desired Scholarship or Fellowship start date. The following should be sent with the application form: A colour photograph of yourself. A scan of a certified Transcript Record Form in English. A scan of a certified copy of your medical diploma. Scans of three letters of reference. Accompanied by a letter explaining the desire for such a training programme. Application Fee A non-refundable EUR 150 application fee is required. The fee includes application to a maximum of 5 programmes. Payment should be made to the EACMFS by bank transfer, details for which are: Volksbank Mittelhessen eg Postfach Giessen, Germany Account No: (BLZ ) IBAN: DE BIC: VBMHDE5F KG/jmcfNov14

2 Please quote your name as reference. Please type into the grey boxes which will expand to fit what you type. Please use mixed upper and lower case, for example United Kingdom. : Date: Last Name: First Name: Address Line 1: Country: Line 2: Line 3: Line 4: Gender: Date of Birth: Telephone: Fax: address(es): Citizenship: Person to notify in case of emergency: Place of Birth: Middle Initial(s): Postcode: 2 MEDICAL LICENSURE / MEDICAL DOCTOR DEGREE Country: University: Date obtained: (Please attach scans of a certified Transcript Record Form in English and a certified copy of your medical diploma.) KG/jmcfNov14 2

3 SPECIALTY: SUBSPECIALTY: FEBOMFS Certified (Date): (if available) Have any of the following ever been or are in the process of being denied, revoked, suspended, reduced, not renewed or voluntarily relinquished (by either resignation or expiration)? 1. License to practice medicine in any jurisdiction 2. Staff membership status or clinical privileges at any other hospital, clinic or health care institution 3. Membership/fellowship in local state, state, or national professional organizations 4. Specialty board certification/eligibility 5. Licence to practice any profession in any jurisdiction 6. Faculty appointment at any medical or other professional school 3 If your answers to any of the above questions are yes, full details should be submitted in an attached document. Please answer the following questions: 1. Do you have any health impairments that affect your ability in terms of skill, attitude or judgement to fully perform professional and medical staff duties? 2. While practicing, has your professional liability insurance carrier ever been sued for your actions within the past five (5) years? Please include any information on malpractice claims or suits against you as well as any malpractice claims or suits that have been filed against you. (If your answer is yes, include the name of present and past insurance carriers and their consent to the release information). 3. Are there now or have there ever been any criminal charges against you? KG/jmcfNov14 3

4 PROFESSIONAL REFERENCES Please list the names and addresses of the three letters of reference you will be submitting with the attached information. 1. Name: 2. Name: 3. Name: SCHOLAR-/FELLOWSHIP PROGRAMME DIRECTOR LIST List the names of Programme Directors you desire to contact. Please note that the EACMFS plays no role in eventual interview or matching processes. Director s name Address 4 In Case of ROTATION Director: Specialty: Time spent (e.g. weekly schedule) Note: The Programme Director(s) is/.are responsible for the whole rotation DISCLOSURE / WAIVER I certify that the information contained in this application form is complete and that I am fully capable and qualified for the training programme. I understand that any KG/jmcfNov14 4

5 significant misstatement in or omission from this application constitutes cause for dismissal from the programme. I authorize the European Association of Cranio-Maxillo-Facial Surgery and its representatives to consult with and seek information regarding my present and past liability and qualifications. I authorize the EACMFS to obtain information regarding my present and past liability insurance coverage, including claims, suits, and settlements made, concluded or pending. I consent the EACMFS inspection of all records and documents that may be material to an evaluation of my professional ability and qualification to carry out the training programme sought by me as well as my ethical qualifications for the training programme. I hereby release from liability all representatives of the EACMFS and their staff for their acts performed in good faith without malice in connection with evaluating me and my credentials. I further release from liability all representatives of the EACMFS and their staff who provide information (including otherwise privileged or confidential information) in good faith with or without malice to a representative of any other health care facility or organization of health care professionals concerning my application for the training programme. 5 KG/jmcfNov14 5

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