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