APPLICATION FOR FELLOWSHIP

APPLICATION FOR IADMFR FELLOWSHIP

Instructions for completing this form: Download Form

1. Type only
2. An application form in digital format can be obtained from the Office of the Secretariat or downloaded from the IADMFR Web site.
3. Be complete. It is important that each item is answered completely to insure full and fair evaluation. Everything is important.
4. If more space is needed, please use additional sheets of paper.
5. Provide most recent information first when giving chronological information.

Return this form to the Secretary-General (a non-refundable fee of USD 400, payable to IADMFR, must be submitted at the time of application):

G.C.H. Sanderink DDS, PhD
Secretary General IADMFR
c/o ACTA
Dept. Oral Radiology
Louwesweg 1
1066 EA Amsterdam
The Netherlands

Personal Information

Last Name:

_________________________________________________________________________

First Name and Middle Initials:

_________________________________________________________________________

Date of birth: ______________________________________________________________

Address: _________________________________________________________________

_________________________________________________________________________

Phone: ___________________________________________________________________

Fax: _____________________________________________________________________

Email: ___________________________________________________________________

IADMFR no: _____________

Member of the IADMFR since: _______________________(Minimum period of five (5) consecutive years)

Attendance at and active contribution to at least two IADMFR Congresses

(please list congress, year, and contribution)

1. ___________________________________________________________________

2. ___________________________________________________________________

3. ___________________________________________________________________

2. Education -qualifications

(please specify: date, degree, speciality, institution and location)

___________________________________________________________

Current and recent professional activity

(please specify: private practice, clinic, School, Research Institution, other appointments

___________________________________________________________

Continuing education -personal professional development

___________________________________________________________

5. Specialty Certification

___________________________________________________________

6. History of professional Career (List activities in chronological order)

___________________________________________________________

7. Dental/Scientific and/or professional organizational involvement.

(specify dates, organisation, leadership positions (not merely membership), committee assignments etc)

___________________________________________________________

8. Publications including editorials.

(list of 10 most recent/important; Specify author(s) , title, Journal/Publisher, vol./page/date)

___________________________________________________________

Total no. of publications ……

Total number in refereed Journals …..

9. Presentations including papers/clinics (list of 10 most recent/important)

Specify title/subject, organisation/site, date

___________________________________________________________

. Honours and awards

Specify date, organisation, and title,

___________________________________________________________

Additional information

(Use this page to continue any items from the previous pages or add additional information about special skills, interests, accomplishments, circumstances, or career path)

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