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OPEN SOCIETY INSTITUTE/SOROS FOUNDATIONS SALZBURG MEDICAL SEMINARS APPLICATION
INSTRUCTIONS
Seminars 2000 DATES AND TOPICS
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:
___ Albania
___ Macedonia
___ Armenia
___ Moldova
Please Specify:
___ Azerbaijan
___ Mongolia
___ Bulgaria
___ Russia (Moscow)
Date____________
___ Croatia
___ Russia (N. Novgorod ____Czech Republic
___ Russia (Novosibirsk)
___ Estonia
___ Russia (Samara)
___ Georgia
___ Russia (St. Petersburg)
___ Hungary
___ Slovakia
___ Kazakstan
___ Slovenia
___ Kyrgyzstan
___ Tajikistan
___ Latvia
___ Ukraine
___ Lithuania
___ Yugoslavia
___ Uzbekistan
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APPLICATION FORM
SALZBURG MEDICAL SEMINARS PROGRAM ******************************************************************************* I.
CONTACT/PERSONAL INFORMATION 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 OF THE SEMINAR
______________ PERSONAL
INFORMATION: 1.
Name: ______________________________________________________
Female
Male
First
Middle
Last 2.
Home address: ______________________________________________________________
street 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 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...
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: ______________
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