Your name:
Your address (For correspondence):
Your address (Place of work, if different from the above):
Telephone (including STD and Extension):
Email:
Medical qualifications:
Date of medical qualifications:
Institute medical qualifications obtained from:
Your date of birth:
Your present age:
Information about your laboratory
Population served by your laboratory:
Total number of histopathology specimens per year:
Total number of autopsies per year:
Number of full-time equivalent histopathologists (NOT trainees) covering the above workload:
Information about your proposed trip
Have you had the opportunity to work abroad before? Give details:
Give an indication of your skills in using written and spoken English, including any English language qualifications such as IELTS and TOEFL
Is there a sub-speciality of histopathology in which you would like to gain further experience
while in the area of the British Division?
What is the return fare (Economy) in Pounds Sterling between your nearest airport and an appropriate airport in
the area of the British Division?
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.
Give a BRIEF summary of your training so far, and your future plans. (maximum 100 words)
Explain briefly how this experience would benefit your institution and the population it serves.
(maximum 100 words)