Fellowship Application
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This application must be accompanied by a complete fellowship plan that should be sent to the Scientific Secretary of EACTA. Without a complete plan the application cannot be processed further.

Fellowship Application

Please fill out this form - click the OK-button and follow the instructions.

Fields with  must be filled in.

 Last Name:
 First Name:
 Title/Position:

Office/Institution:
Department:
Office Address:
City:
State:
Postal Code:
Country:

Tel.:
Fax:
 E-mail:

Home Address:
City:
State:
Postal Code:
Country:

Preferred mailing address:

Office
Home

Support from home institution:
(Head of Department/Hospital administrator)

Name:

Institution to visit:

Name:
Department:
Address:
Zip:
City:
Country:

Contact person at Institution:

Name:
E-mail address:
Fax number:
Preferred/Agreed
Starting time:

Benefit and achievement from visit:
(max 255 characters)

Benefit and achievement:

   
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