ERA-EDTA COMMITTEE FOR INTERNATIONAL AFFAIRS CLINICAL FELLOWSHIP PROGRAMME RULES

This application is for a special clinical fellowship programme for fellows living in countries outside of the ERAEDTA geographical area. Following rules and regulations apply: a) ERA-EDTA is willing to sponsor long term, or short term, fellowships each year for persons living in developing countries who, according to the current ERA-EDTA fellowship regulations, would otherwise not be able to participate in the regular ERA-EDTA fellowship programme. b) These special fellowships are for persons living in developing countries outside of Europe (or countries bordering Europe and the Mediterranean Sea). c) The fellowship must be done in a country in Europe and the fellow, at the end of the training, must return back to his/her country of origin. d) The International Committee will be in charge of evaluating the fellowship requests. A short project should be written (1 page) and sent directly to the International Committee by the candidate. The International Committee should evaluate the feasibility of the project (application of tolerance principal or positive discrimination instead of scientific levels as is instead requested for the regular ERA-EDTA fellowship programme). e) If feasible the International Committee will inform the Council accordingly: in fact it will be the Council that will be in charge of granting the fellowship. At the end of the fellowship a short report (1 page) should be drafted and sent to the International Committee to verify that indeed the fellow did fulfill the request of the application. f) If applicable, the Officers in charge of signing this agreement with the National Society will be the ERAEDTA President and Secretary-Treasurer.

g) This special fellowship programme will have a budget that will be decided, by Council, on an annual basis, preferably at the Fall/Autumn meeting.

Please, return this form to Ms. Muguet Koobasi, Administrative assistant ERA-EDTA Committee International Affairs, Nephrology Section 0K12A, University Hospital Ghent, De Pintelaan 185, BE-9000 GHENT, BELGIUM muguet.koobasi@ugent.be, fax: +32 (0)9 332 45 99 no later than September 30, 2013

ERA-EDTA COMMITTEE FOR INTERNATIONAL AFFAIRS CLINICAL FELLOWSHIP PROGRAMME APPLICATION

Number of the application (to be filled out by the Fellowship Office):

Applicants first name:

Applicants surname:

Applicants e-mail address:

KIND OF CLINICAL FELLOWSHIP

Are you applying for (please check the appropriate box): a) Long-Term Fellowship: intended for advanced training through clinical activities Duration allowed: 6 to 12 months b) Short-Term Fellowship: intended for two different possibilities: 1) promoting a clinical collaboration between two institutions 2) training in specific clinical techniques Maximum duration allowed: 3 to 4 months

Proposed duration of the fellowship (days/months):

Intended starting date (dd.mm.yyyy):

APPLICANTS DATA
Correspondence address:

Nationality:

E-mail address:

Telephone number: + Mobile number: +

Date of birth (dd.mm.yyyy):

Marital status:

Childrens age (if any) of the applicant: Education Please list, in chronological order, your education and training prior to your final exams, starting from the beginning of your university (or equivalent) studies. Please state the duration, the university, major subjects, and the degrees obtained, if applicable. You may also list stages of your pre-university education and any professional, non-academic positions held in the past, as well as any relevant fellowships and awards you have previously received

CV Please list in chronological order, your postgraduate training and positions held since passing your final exams. Please also state the duration, kind of training or position, the clinical or scientific area, the research topic, the supervisor, and the institute, if applicable

MD/PhD and Post-Doc information:

Present position

Name and full address of the current institution:

Synopsis of your current work Please provide a description of your current work (max 1500 words)

Publications List of (co-) authored, peer-reviewed publications (excluding review articles or manuscripts submitted or in preparation), in chronological order. Please indicate by an asterisk the three most important publications in your list. In the case of shared first authorship, please keep the order of authors as they appear on the original publication 1)

Other grants List of previously held fellowships from ERA-EDTA or other organizations with dates (month/year):

Have you previously applied for ERA-EDTA funding? If yes, please state the duration and dates:

Have you recently interrupted your career due to child care? If yes, please state the duration and dates:

PROJECT INFORMATION
Title of project:

Please write one page on the project:

RECEIVING INSTITUTE
Please add the following data Name of the receiving institution: Supervisors name: Supervisors e-mail address: Supervisors phone number: + Receiving Institute full address:

Justification of receiving institute choice:

Receiving institute acceptance form Please download Form of Acceptance of Applicant by Receiving Institute from the ComIA website and send it to the receiving institute. The Receiving Institute has to forward it to us (muguet.koobasi@ugent.be) properly filled in. Summary of the proposed clinical training Please provide an about 200 word summary of the proposed activity

Proposed work at the receiving institute Please provide the synopsis of the proposed activity at the receiving institute, no more than 1500 words

Return travel and living costs estimate Please provide an estimate cost in EUR for your return travel and living costs during the fellowship including the institutions overheads and various necessary taxes :

Career plan after the clinical fellowship Please describe which are you future professional plans

Please, return this form to Ms. Muguet Koobasi, Administrative assistant ERA-EDTA Committee International Affairs, Nephrology Section 0K12A, University Hospital Ghent, De Pintelaan 185, BE-9000 GHENT, BELGIUM muguet.koobasi@ugent.be, fax: +32 (0)9 332 45 99 no later than September 30, 2013