Salzburgo seminarai

Buvę Salzburgo seminarų dalyviai kviečiami dalyvauti šiuose seminaruose:

Pediatric Gastroenterology and Child Nutrition: January 16 – 22

Cardiology: February 6 – 12

Adolescent Medicine, Emergency Care in Pediatrics: February 13 – 19

Maternal/Infant Health: March 4 – 10

Paraiškų pateikimo terminas: 1999 m. gruodžio 5 d. Paraiškas siųsti V. Ambrazevičienei, Atviros Lietuvos fondas, A.Jakšto 9, LT-2600 Vilnius.

OPEN SOCIETY INSTITUTE/SOROS FOUNDATIONS

SALZBURG MEDICAL SEMINARS

2000

APPLICATION INSTRUCTIONS

Complete the attached form in ENGLISH and return it to the local Soros Foundation in your country by ______________.

Please attach to the application form:

*one photograph

*one recommendation from a colleague who knows your work. If possible, he or should be from the professional society in your country (eg.Society of

Anesthesiologists, Psychiatrists, etc...)

*one copy of your medical diploma and license

*CV (curriculum vitae) or resume

Country of origin (check one): Seminar (check one):

__ Albania __ Moldova __ Pediatric Gastroenterology

and Child Nutrition

__ Armenia __ Mongolia __ Cardiology

__ Azerbaijan __ Poland __ Adoloescent Medicine

__ Bosnia and __ Romania __ Emergency Care in Pediatrics

__Herzegowina __ Russia (Moscow) __ Maternal/Infant Health

__ Bulgaria __ Russia (Novosibirsk) __ ENT ¹⁾

__ Croatia __ Russia (N.Novgorod) __ Bone and Joint Surgery

__ Chech Republic __ Russia (Samara) __ Infectious Diseases

__ Estonia __ Russia (St. Petersburg) __ Oncology

__ Georgia __ Russia (Wladivostok) __ Imaging

__ Hungary __ Slovakia __ Obstetrics/Gynecology

__ Kazakhstan __ Slovenia __ Anesthesiology

__ Kyrghyztan __ Tajikistan __ Family Medicine

__ Latvia __ Ukraine __ Urology

__ Lithuania __ Uzbekistan __ Neurology

__ Macedonia __ Yugoslavia __ Psychiatry

__ Family Medicine

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Applicationform

Salzburg Medical Seminars Program 2000

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I Contact/Personalinformation

have you ever applied for participation in a salzburg cornell seminar?

___________ (Yes/No)

If yes, did you participate in a seminar in salzburg? ___________ (Yes/No)

If yes, please provide the date and name of the seminar ___________________

Personal information:

1. Name: ___________________________ ____________________ ð Female ð Male

lastname (surname) firstname (givenname)

2. Home address: _____________________________________________________________

city postal code country

Home telephone: _____________________________________

3. Work address: ______________________________________________________________

Name of the Institution and Department

______________________________________________________________

street address

______________________________________________________________

city postal code country

Work telephone:___________________________________

Fax/Telex: _______________________________________

Email: ___________________________________________

4. Date of Birth: _______________ Place of Birth: ___________________________________

mm/dd/yy

Personal ID Number: ________________________________

5. Country of Citizenship: ____________________________________________________

6. Marital Status: ¨ Single ¨ Married ¨Divorced Number of Dependents: ____

II. EDUCATION

Medical School/Institute:

_________________________________________________________________________

name city & country

_________________________________________________________________________

dates attended degree

_________________________________________________________________________

specialty

Other University/College:

1. _________________________________________________________________________

name city & state

_________________________________________________________________________

dates attended degree

2. _________________________________________________________________________

name city & state

_________________________________________________________________________

dates attended degree

Practical Training (internships, residencies, specializations, other practical training or fellowships):

1. _________________________________________________________________________

name of institute/hospital location

_________________________________________________________________________

specialty dates

2. _________________________________________________________________________

name of institute/hospital location

_________________________________________________________________________

specialty dates

3. _________________________________________________________________________

name of institute/hospital location

_________________________________________________________________________

specialty dates

Medical license number: _____________________________________ date issued: ___________

Have you had any training or attended any medical conferences abroad?___________ (Yes/No)

If yes, please describe:_____________________________________________________________

_______________________________________________________________________________

III. PROFESSIONAL EXPERIENCE

1. Describe your current professional position and responsibilities:

_______________________________________________________________________________

Other (previous) work experience:

_______________________________________________________________________________

2. List fields of special scientific or clinical interest:

_______________________________________________________________________________

3. List any teaching appointments you have or have held:

_______________________________________________________________________________

4. List below (or on a separate sheet) titles of any papers you have presented at conferences:

_______________________________________________________________________________

5. List below (or on a separate sheet) titles of any publications:

_______________________________________________________________________________

6. List any positions you hold with professional organizations or societies:

_______________________________________________________________________________

7. List any awards or honors:

_______________________________________________________________________________

IV. KNOWLEDGE OF LANGUAGES

Please evaluate your knowledge of foreign languages. Indicate the level of your speaking, reading and writing abilities in the chart below by writing: excellent, good, fair, poor in the appropriate box. Please list and evaluate your abilities in any other languages that you know such as German, French, etc...

LANGUAGES:	Ability to SPEAK	Ability to READ	Ability to WRITE
ENGLISH

V. ESSAY SECTION

1. Describe below your reasons for applying for this fellowship and what you hope to accomplish.

_______________________________________________________________________________

2. Describe how you will share the information you gain abroad with your colleagues back home upon return to your country.

_______________________________________________________________________________

VI. RECOMMENDATION

Please list the name and title of the professional, who has recommended you for this program. (attach the letter of recommendation to this form)

Name: ____________________________________

Title: ____________________________________

Institute: ____________________________________

VII. SIGNATURE

I certify that the information given in this application is complete and accurate to the best of my knowledge.

Signature: _________________________________ Date: ______________