APPLICATION FOR LEIBINGER PRIZE

    Surname/Nom/Name (required)

    First Name/Prenom/Vorname

    Date of Membership of EACMFS

    Present Post/Appointment

    Address/Adresse/Anschrift

    Date of Appointment

    Details of Centre to be visited (please consult the available list)

    Name of Hospital/Institute (this will normally be within Europe)

    Head of Department

    Nature of study/experience to be gained

    Proposed dates of visit (should not normally exceed three months)

    Estimated expenses(€uro):
    (a) travelling ________________________
    (b) subsistence ______________________

    Documentary support

    1. Head of Department of present post/appointment

    I support this application and confirm that a salary will continue to be paid during the period of leave of

    absence

    _______________________(signature)

    _______________________(Name)

    2. Confirmation that written approval has been received from the Head of Department to be visited

    (please enclose a copy with this application) YES/NO

    3. EACMFS Council Member (normally the appropriate National Councillor)

    I am aware of the applicant's training and abilities and support this submission

    _______________________(signature)______________________(Name)

    I agree that if successful in this application I will submit a report to the Secretary-General within three

    months of returning and that the copyright of any paper resulting from the scholarship will rest initially

    with the Editor-in-Chief of the Journal of Cranio-Maxillofacial Surgery

    _______________________(signature)______________________(Date)

    Eacmfsleibscholarapplicoct10

    PLEASE APPEND DETAILED CURRICULUM VITAE (to include details of previous appointments with

    dates/prizes/awards/distinctions etc and publications)

    PLEASE HIGHLIGHT BELOW

     Career aspirations

     Contributions already made to the specialty

     The aims, objectives and gains anticipated from the training programme which it is planned to

    visit. Please note this should preferably be within Europe, allow active participation in clinical

    patient care and normally be of not more than three months duration

    Your Email (required)

    Subject

    Your Message