Applications on the approved proforma together with supporting documentation should sent to the above address to arrive no later than 31 January for consideration in March or 31 July for consideration in September of  each year.


                            European Association for Cranio-Maxillofacial Surgery
                                                     (EACMFS)
                                                 ENDOWMENTS COMMITTEE

APPLICATION FOR EACMFS TRAVELLING SCHOLARSHIP

(Please type or use BLOCK CAPITALS and ensure that both sides are completed)

Surname/Nom/Name___________________________________________________

First Name/Prenom/Vorname_________________________________________________

Qualifications(Date and Institute)______________________________________________________

Date of Membership of EACMFS_____________________________________________________

Present Post/Appointment______________________________________________________


Address/Adresse/Anschrift_______________________________________________
________________________________________________________________________________________
    ____________________________________________

Date of Appointment__________________________________________________________


Details of  Centre to be visited:

Name of Hospital/Institute_______________________________________________________

Head of Department___________________________________________________________

Nature of study/experience to be gained ____________________________________________________________________
_____________________________________________________

Documentary support

2. Head of Department of present post/appointment

I support this application and confirm that a salary will continue to be paid during the period of leave of absence

____________________________(signature)

____________________________(Name)


2. Confirmation that written approval has been received from the Head of Department to be visited
    (please enclose a copy with this application)   

YES/NO


3. Member of Council of EACMFS (normally the appropriate National Councillor)

I am aware of the applicant's training and abilities and support this submission

 
___________________________(signature)

___________________________(Name)



I agree that if successful in this application I will submit a report to the  Secretary-General within three months of returning and that the copyright will rest initially with the Editor-in-Chief of the Journal of Cranio-Maxillofacial Surgery
       

___________________________(signature)


________________(Date)

SUMMARY OF CURRICULUM VITAE (Please include details of previous appointments with dates/prizes/awards/distinctions etc and  publications)





































Please return this application form when FULLY completed to:
Dr John Lowry
Secretary General EACMFS
The Clock House
39 North Street
Midhurst
West Sussex GU29 9DS
ENGLAND

Applications must be received no later than 31 January for consideration in March or 31
July for consideration in September by the Endowments Committee each year