Online Application Form

Basic information

Hospital

University affilliation

Name of candidate

Date of birth

Afghanistan Albania Algeria Andorra Angola Argentina Armenia Aruba Australia Australian External Territories Austria Azerbaijan Bahrain Bangladesh Belarus Belgium Belize Benin Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Caribbean Netherlands Central African Republic Chad Chile China Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti DR Congo Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Japan Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue North Korea North Macedonia Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Reunion / Mayotte Romania Russia Rwanda Saint Helena Saint-Pierre & Miquelon Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Wallis & Futuna Yemen Zambia Zimbabwe Country

Email

Number of endocrine surgeries performed

Number of operations performed annually

Thyroid

Parathyroid

Adrenal

GEP-NET

Extra information

History of training, career profile (state degree, qualifications, hospital and mentors, etc.)

Main field of interest

Specific goal of travel fellowship

Involvement in the ESES by surgeons at the applying host institution

Member (junior) of the ESES since

Senior ESES member supporting application

Participation at ESES meetings (year)

List of abstracts presented at ESES meetings (year)

DES examination in endocrine surgery:

Yes

No

List of publications on endocrine topics in the last 3 years

Specify languages and level of competence to communicate/converse with clinicians

List of priority of centres/mentors to visit

Priority 1

Centre

Mentor

Full time scholarship

Preferred period of scholarship

Priority 2

Centre

Mentor

Full time scholarship

Preferred period of scholarship

Priority 3

Centre

Mentor

Full time scholarship

Preferred period of scholarship

List of priority of specific surgeries/disease management type to experience

Priority 1

Organ

Type of surgery

Full time scholarship

Preferred period of scholarship

Priority 2

Organ

Type of surgery

Full time scholarship

Preferred period of scholarship

Priority 3

Organ

Type of surgery

Full time scholarship

Preferred period of scholarship

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