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THE EUROPEAN ASSOCIATION FOR CARDIO-THORACIC SURGERY |
THE FRANCIS FONTAN PRIZE APPLICATION FOR FELLOWSHIP
Family name ........................................................... First name : ............................................................................
Date of birth : ........................................................
Hospital address : ...................................................................................................................................................
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Zip code |
City |
Country |
Phone no. .........................................................Fax no. ..........................................................................................
E-mail: .................................................................................................................................................................
Private address : ....................................................................................................................................................
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Zip code |
City |
Country |
Phone no. ........................................................ Fax no. .........................................................................................
No. of years in medical training since graduation ..........................................................................................................
Type of interest/practice :
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Predominantly thoracic O |
Predominantly cardiac O |
Both O |
Please make sure that your application is complete. See Rules.
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Applicant's signature
Mail to:
EACTS Executive Secretariat
3 Park Street, Windsor, Berkshire SL4 1LU, UK
Tel +44 (0)1753 832166, Fax +44 (0)1753 620 407
E-mail: info@eacts.co.uk
