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Fellowship application for CMF surgeons(We accept only typed out forms)
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Personal information
First name:
Family name:
Date of birth (DDMMYYYY): Male Female
Nationality: Marital status:
Title/Degrees
BSc DDS Dr FACS FRCS FRCSC MBA MD MPH PhD Prof
Other:
Contact details:
Phone: Fax:
Mobile:
Email: Skype:
Work address Please use as mailing address
Organization/Institution:
Position:
Department:
Street address:
Country: City:
State/region: Postal code:
Private address Please use as mailing address
Street address:
Country: City:
State/region: Postal code:
Languages
Fluent Oral Fluent Written Fluent Oral Fluent Written
Arabic Japanese
Cantonese Mandarin
English Portuguese
French Russian
German Spanish
Italian
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Medical schooling
Name of school:
Street address:
Country: City:
State/region: Postal code:
Duration:
Date of graduation (DDMMYYYY):
Dental school
Name of school:
Street address:
Country: City:
State/region: Postal code:
Duration:
Date of graduation (DDMMYYYY):
Post-graduate education
Where:
Duration:
Qualication:
Where:
Duration:
Qualication:
Have you applied the AO principles and techniques? Yes No
Which implants and instruments were used?
Where (eg. Trauma, Tumor, Orthognatics):
How long have you been using them?
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What do you expect from your stay in an AOCMF Fellowship unit?
In which elds are you particularly interested?
Facial Traumatology Head & Neck Oncology Orthognathic Surgery Craniofacial Surgery
Scull Base Surg. Navigation Imaging Endoscopy Others:
Have you attended an AOCMF Principles Course? Yes No
If yes, where and in which year? (Please enclose a copy of your certicate)
If no, when do you plan to attend one?
Please note: AOCMF Fellowships are only granted to candidates who have completed
an ofcial AOCMF Principles Course (workshops, seminars, etc are not acceptable).
Are you interested in research? Yes No
In which areas?
Are you active in research? Yes No
Clinical and/or experimental? Please explain:
Have you written any publications? Yes No
(Please attach your bibliography)
What are your future professional goals?
(Please answer as precisely as possible. We wish to consider your future professional goals when assigning your training clinic)
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Where do you plan to continue your career? Hospital Clinic Private Practice
See Organization/Institution
Do you have another denitive appointment? Yes No
Where:
Position:
Expected duration if fellowship is granted: 4 weeks 6 weeks 8 weeks other
Please indicate the most convenient date(s):Please note: The months of July and August are generally not recommended due to the summer holidays.
Do you have any preferred AOCMF Fellowship unit
1st Choice:
2nd Choice:
Country:
No preference
If you are granted an AOCMF Fellowship, do you plan to come alone? Yes No(Please note: we can only provide single accommodation)
Which AO members do you know personally?(Please explain your association with them)
Other references:
Remarks:
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Please send completed form to:AO Foundation | AOCMF | Fellowships
Stettbachstrasse 6, 8600 Dbendorf, Switzerland
Phone: +41 44 200 24 83, Fax: +41 44 200 24 21
[email protected], www.aocmf.org
I have read the AOCMF Fellowship program guidelines and hereby accept all conditions.
Place, Date: Signature:
Please enclose the following documents with your application:
Curriculum vitae
Copy of medical school / dental school diploma
Copy of AO Principles Course Certicate
Two letters of recommendation of AO Members
List of publications and major lectures given by the applicant
One recent passport size photograph
Health Certicate (see page 6 in brochure)
If English is neither the applicants mother tongue nor the language used by the host clinic, please enclose
evidence of attendance at an English language course or a course of the language of the host clinic.