| FAMILY NAME: | .......................................................................................... |
| FIRST NAME: | .......................................................................................... |
| DATE OF BIRTH: | .......................................................................................... |
| NATIONALITY: | .......................................................................................... |
| MARITAL STATUS: | .......................................................................................... |
| PERMANENT HOME ADDRESS: | .......................................................................................... .......................................................................................... .......................................................................................... |
| HOME TEL. NO.: | .......................................................................................... |
| NAME OF UNIVERSITY/HOSPITAL: | .......................................................................................... .......................................................................................... |
| ADDRESS OF HOSPITAL: | .......................................................................................... .......................................................................................... |
| HOSPITAL/OFFICE TEL.NO: | .......................................................................................... |
| HOSPITAL/OFFICE FAX NO: | .......................................................................................... |
| YOUR POSITION: | .......................................................................................... |
| 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: | .......................................................................................... |
| DO YOU UTILIZE ORIGINAL AO/ASIF INSTRUMENTS: | ( ) YES ( ) NO |
| ARE YOU RESEARCH ORIENTED: | ( ) YES ( ) NO |
| IN WHICH AREAS: | .......................................................................................... |
| ARE YOU CURRENTLY ACTIVE IN RESEARCH: | ( ) YES ( ) NO |
| CLINICALLY, EXPERIMENTALLY? PLEASE EXPLAIN: | ......................................................................................... ......................................................................................... |
| PUBLICATIONS: (please attach your bibliography) | ( ) YES ( ) NO |
| IN WHICH FIELDS ARE YOU PARTICULARLY INTERESTED? (trauma, hand surgery, maxillofacial surgery, others) | ....................................................................................... ....................................................................................... |
| WHERE AND WHEN DID YOU TAKE THE AO BASIC COURSE? | ....................................................................................... |
| WHERE AND WHEN DID YOU TAKE THE ADVANCED COURSE? | .................................................................................. |
| ARE YOU AN AO FACULTY MEMBER? | ( ) YES ( ) NO |
| ARE YOU AN AO NORTH AMERICA MEMBER? | ( ) YES ( ) NO |
| WHAT DO YOU EXPECT FROM YOUR ALLGÖWER FELLOWSHIP EXPERIENCE AND WHERE WOULD YOU LIKE TO GO TO TAKE IT? PLEASE BE AS DETAILED AS POSSIBLE. | |
| ............................................................................................................................................................................. ............................................................................................................................................................................. | |
| WHEN WOULD YOU LIKE TO TAKE THE FELLOWSHIP? | ....................................................................................... |
| SIGNATURE: | ................................................................................................................................ |
| DATE: | ................................................................................................................................ |
PLEASE ENCLOSE THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION:
1) MINIMUM OF TWO NEW LETTERS OF RECOMMENDATION AO North America
2) CURRICULUM VITAE
3) LIST OF PUBLICATION AND/OR LECTURES
4) 2 PHOTOGRAPHS
Please send completed form to:
1690 Russell Road
Paoli, PA 19301-0800
USA