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Your name:* |
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Your address (For correspondence):* |
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Your address (Place of work, if different from
the above): |
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Telephone (including STD and Extension): |
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Email:* |
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Medical qualifications:* |
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Date of medical qualifications:* |
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Your date of birth:* |
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Your present age:* |
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Information about your laboratory
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Population served by your laboratory:*
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Total number of histopathology specimens per year:*
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Autopsies per year:*
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Number of full-time equivalent histopathologists
(NOT trainees) covering the above workload:*
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Information about your proposed trip
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Conference days you wish to attend:*
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Details of proposed oral or poster presentation. Please note that applications will not be considered without an abstract, which should be e mailed to Dr S Wells, contact details on previous page*
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What is the return fare (Economy) in Pounds Sterling
between your nearest airport and an appropriate
airport in the area of the British Division?*
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Please give the names, postal addresses and (if
available) email addresses of two pathologists,
one of whom should be your Head of Department, who
are willing to support your application with a reference.**
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Give
a BRIEF summary of your training so far, and your
future plans. (maximum 100 words)* |
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Explain briefly how this experience would benefit
your institution and the population it serves. (maximum
100 words)* |
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