ONLINE APPLICATION FORM - ESES - EUROPEAN SOCIETY OF ENDOCRINE SURGEONS

Fields with asterisk (*) required.
Hospital*
University affilliation*
Country*
Name of candidate*
Date of birth*
E-mail*
Number of endocrine surgeries performed*
Number of operations performed annually:
Thyroid*
Parathyroid*
Adrenal*
GEP-NET*
History of training, career profile (state degree, qualifications, hospital and mentors, etc.):*	(Characters left: 2500)
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)*	(Characters left: 2500)
DES examination in endocrine surgery*	yesno
List of publications on endocrine topics in the last 3 years*	(Characters left: 2500)
Specify languages and level of competence to communicate/converse with clinicians*	(Characters left: 300)
List of priority of centres/mentors to visit - priority 1
centre*
mentor*
full time scholarship*
preferred period of scholarship*
List of priority of centres/mentors to visit - priority 2
centre*
mentor*
full time scholarship*
preferred period of scholarship*
List of priority of centres/mentors to visit - 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*
List of priority of specific surgeries/disease management type to experience - priority 2
organ*
type of surgery*
full time scholarship*
preferred period of scholarship*
List of priority of specific surgeries/disease management type to experience - priority 3
organ*
type of surgery*
full time scholarship*
preferred period of scholarship*