Application for Training in an AO Clinic
| FAMILY NAME: | .......................................................................................... |
| FIRST NAME: | .......................................................................................... |
| DATE OF BIRTH: | .......................................................................................... |
| NATIONALITY: | .......................................................................................... |
| MARITAL STATUS: | .......................................................................................... |
| PERMANENT HOME ADDRESS: | .......................................................................................... .......................................................................................... .......................................................................................... |
| HOME TEL. NO.: | .......................................................................................... |
| E-MAIL ADDRESS: | .......................................................................................... |
| NAME OF UNIVERSITY/HOSPITAL: | .......................................................................................... .......................................................................................... |
| COMPLETE ADDRESS OF HOSPITAL: (if you are in private practice, please explain your position and indicate name and address of the hospital) | .......................................................................................... .......................................................................................... |
| HOSPITAL/OFFICE TEL.NO: | .......................................................................................... |
| HOSPITAL/OFFICE FAX NO: | .......................................................................................... |
| PRESENT POSITION: | .......................................................................................... |
| CHIEF OF CLINIC: | .......................................................................................... |
| NAME OF HEAD OF DEPARTMENT: | .......................................................................................... |
| [ ] ENGLISH | [ ] FRENCH | [ ] GERMAN | [ ] SPANISH | OTHERS: .................................... |
| NAME OF SCHOOL(S): | ........................................................................................... |
| ADDRESS: | ........................................................................................... |
| DURATION: | ........................................................................................... |
| DATE OF GRADUATION: | ........................................................................................... |
| where: | .......................................................................................... |
| duration: | .......................................................................................... |
| qualification: | .......................................................................................... |
| where: | .......................................................................................... |
| duration: | .......................................................................................... |
| qualification: | .......................................................................................... |
| where: | .......................................................................................... |
| duration: | .......................................................................................... |
| HAVE YOU USED THE ORIGINAL AO/ASIF INSTRUMENTS: | ( ) YES ( ) NO |
| WHERE: | .......................................................................................... |
| HOW LONG: | .......................................................................................... |
| OR COPIES / OTHER: | ( ) YES ( ) NO |
| WHICH PRODUCTS AND WHERE: | .......................................................................................... |
| ARE YOU RESEARCH ORIENTED: | ( ) YES ( ) NO |
| IN WHICH AREAS: | .......................................................................................... |
| INTEREST IN RESEARCH: | ( ) YES ( ) NO |
| CLINICALLY, EXPERIMENTALLY? PLEASE EXPLAIN: | ......................................................................................... ......................................................................................... |
| PUBLICATIONS: (please attach your bibliography) | ( ) YES ( ) NO |
| WHAT DO YOU EXPECT FROM A STAY IN AN AO CLINIC? | ....................................................................................... ....................................................................................... |
| IN WHICH FIELDS ARE YOU PARTICULARLY INTERESTED? (trauma, hand surgery, maxillofacial surgery, others) | ....................................................................................... ....................................................................................... |
| HAVE YOU ATTENDED AN AO/ASIF BASIC COURSE? | ( ) YES ( ) NO |
| IF YES, WHERE ONE AND WHAT YEAR: (Please enclose a copy of your certificate) | ....................................................................................... |
| IF NOT, WHEN DO YOU PLAN TO ATTEND ONE: | .................................................................................. |
| PLEASE NOTE: AO Fellowships are only granted to candidates who have completed an official AO/ASIF Basic course (workshops, seminars etc. are not acceptable) |
| DO YOU PLAN TO CONTINUE YOUR CAREER AT THE SAME CLINIC? | ....................................................................................... ....................................................................................... |
| DO YOU HAVE ANOTHER DEFINITE APPOINTMENT? | ( ) YES ( ) NO |
| where: | ....................................................................................... |
| position: | ....................................................................................... |
| EXPECTED DURATION IF FELLOWSHIP IS GRANTED: | .................................................................. WEEKS |
| PLEASE INDICATE THE MOST CONVENIENT DATE(S): | .................................................................. |
| PLEASE NOTE: The months of July and August are generally not recommended due to the summer holiday with reduced staff etc. However, clinics with frequent polytrauma are in full activity during summer months. | |
| IF YOU ARE GRANTED AN AO/ASIF FELLOWSHIP,ARE YOU PLANNING TO COME ALONE? | ( ) YES ( ) NO |
| ACCOMMODATION: A single room is normally provided either within the hospital complex or nearby (not in USA/Canada). In USA and Canada the fellow has to organize his accommodation personally but usually the hospital office will help him in this matter. Please note that housing is expensive and scarce. Bringing a partner and children can cause problems since AO International cannot cover hotel expenses. Nor can the personnel of AO, or the host hospital, arrange housing for the fellow and his/her family. If however family housing is required then these arrangements will have to be made privately by the fellow himself. This can prove difficult and expensive. We also know from experience that living outside the hospital complex reduces active participation and thus impairs the professional benefit of the stay. For this reason, together with the financial difficulties, we strongly recommend coming alone and living in the hospital accommodation provided. | |
| WHICH AO MEMBERS DO YOU PERSONALLY KNOW? PLEASE EXPLAIN YOUR ASSOCIATION WITH THEM: | ................................................................... ................................................................... ................................................................... |
| OTHER REFERENCES: | ................................................................... ................................................................... ................................................................... |
| ADDITIONAL REMARKS: | ................................................................... ................................................................... ................................................................... |
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I HAVE READ THE ENCLOSED INSTRUCTION FORM AND ACCEPT HEREBY ALL CONDITIONS:
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PLEASE ENCLOSE THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION:
1) CURRICULUM VITAE AO North America
2) COPY OF YOUR MEDICAL SCHOOL DIPLOMA
3) COPY OF YOUR BASIC COURSE CERTIFICATE
4) MINIMUM OF TWO NEW LETTERS OF RECOMMENDATION
5) LIST OF PUBLICATION AND/OR LECTURES
6) 2 PHOTOGRAPHS
THIS COMPLETED FORM MUST BE RETURNED TO:
1690 Russell Road
Paoli, PA 19301-0800
USA