ISPD FELLOWSHIP PROGRAM

APPLICATION FORM

The completed application form must be accompanied by the following documents:

A Personal application letter (word or pdf file)

A personal curriculum vitae ((word or pdf file)

A supportive letter from head of the home Department or Hospital (word or pdf file)

An acceptance letter from the trainer (word or pdf file)

Application Submission Deadline: March 31 or September 30

Applications may be submitted by mail, fax or e-mail to the ISPD Headquarter:

ISPD Global Operations Center

Rue des Fabriques 1B
B1000 Brussels, BELGIUM
E-mail: admin@ispd.org
Fax: +32 2 808 44 454
Phone: + 1 567 251 4018

INFORMATION ABOUT CANDIDATE AND HOME INSTITUTION

Family Name:
Given Name:
Year of Birth:
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Gender: Male Female
Country:
ISPD Membership: YES NO
E-mail:
Corresponding Address:
Institution Name:
Institution Address:
Position:
Head of the Department:

INFORMATION ABOUT TRAINER AND TRAINING INSTITUTE

Trainers Family Name:

Trainers Given Name:

Trainer Title:

ISPD Membership: YES NO

Training Institute:

Training Institute Address:

INFORMATION ABOUT TRAINING AND BUDGET

Training Duration:
Tentative Training:
Period:
Amount applied: USD
Budget breakdown:
Travelling:
Accommodation:
Living Expenses:
Insurance:
Others (please specify):

Rationale for applying ISPD Fellowship (MAX 250 words)

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Your future plan after training: (MAX 250 words)

FOR ISPD OFFICIAL USE

Approval: YES NO

Amount Approved by ISPD:

Remarks:

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