INTERNATIONAL SOCIETY OF NEPHROLOGY
INTERNATIONAL FELLOWSHIP TRAINING AWARD
APPLICATION
NOTE: THIS APPLICATION CONSISTS OF FOUR (4) PAGES
Please type or print:
| First Name | _____________________________________ | Sex: Male [ ] Female [ ] |
| Family Name | _____________________________________ | |
| Nationality | _____________________________________ | Birth date: dd/mm/yy ____/____/____ |
| Professional Address | _____________________________________ | |
| (+fax + E-Mail) | _____________________________________ | |
| _____________________________________ | ||
| Head of Department | _____________________________________ | |
| (+fax + E-Mail) | _____________________________________ | |
| Medical School | _____________________________________ | |
| Date of Graduation | _____________________________________ | |
| Postgraduate training | _____________________________________ | |
| _____________________________________ | ||
| _____________________________________ | ||
| Institution (full address) where Fellow will receive training: | ||
| _____________________________________ | ||
| _____________________________________ | ||
| _____________________________________ | ||
| Host Mentor | _____________________________________ | |
| (+fax + E-Mail) | _____________________________________ | |
| Training Period (in months) | _____________________________________ | Start Date: dd/mm/yy ____/____/____ |
| Institution where Fellow will have his/her post | ||
| training position | _____________________________________ | |
| (full address + fax) | _____________________________________ | |
| _____________________________________ | ||
| _____________________________________ | ||
| Signature of Applicant: | _____________________________________ | |
National Society endorsement: The National Society of _____________________________________ |
||
hereby supports the Fellowship application of _____________________________________ |
||
| Signature of Society Officer _____________________________________ | ||
April 1998