General Information - Application of GSF

Application for The Gordon Signy Fellowship of the World Pathology Foundations (WPF)

Due Date: June 30, 2008 for the application of the study in calendar year 2009.
(Application for the study in calendar year of 2008 was closed on June 30, 2007)

Please complete and send to the Secretary of WPF by both air mail and E-mail.

World Pathology Foundation
c/o Ms. Madeleine Luetzelschwab
Lerchenstrasse 25
CH-4059 Basle
phone: +41 61 265 42 34
fax: +41 61 265 53 33
email: MLuetzelschwab@uhbs.ch

A) Applicant
Family name:
Given names:
Sex:
Date of birth:
Nationality:
Place of current employment and address:
Telephone number:
Fax number:
E-mail number:

B) Medical education
Applicants university:
Medical degree obtained:
Date of degree:
State training undertaken in pathology:
Discipline:
Period of time:
State if accreditated in pathology with details:
Diploma:
Accreditation certificate:
Any other certificate:

C) Proposed studies:
Place (give department, institution and country):
Duration:
Nature of training including methodology:
Please indicate relevance of this proposed study to future practice in the applicants country.

D) Name and title of head of department supporting the proposed study.
Attestation to be signed by the applicant together with written confirmation granting the applicant a place.

I certify that if I am awarded a Gordon Signy Fellowship I will return to the country in which I now practice, to make available to the people of this region the skills I have obtained.

The fund granted if I am awarded a Gordon Signy Fellowship is my only claim against the World Pathology Foundation.

After the conclusion of the Fellowship, I will send the World Pathology Foundation report of my activities while holding the Fellowship, and an assessment of their value.

Date:

Signed by the applicant