Application form

European Board of Thoracic and Cardiovascular Surgeons

APPLICATION FORM PART I

Office: P.O. Box 2023

1990 AA Velserbroek

The Netherlands

Phone: +31 - 255 - 520950

FAX: +31 - 255 - 523353

e-mail: ebtcs@wxs.nl

(Please complete in capitals)

Name: ____________________________________________________________________________

First Name: ________________________________________________________________________

Title (Prof., Dr. Mr., Mrs.): ____________________________________________________________

Date of birth: _______________________________________________________________________

Nationality: _________________________________________________________________________

Address: Street: ______________________________________________________________________

City: _______________________________________________________________________________

Postal Code: _________________________________________________________________________

Country: ____________________________________________________________________________

Telephone: ___________________________________________________________________________

Facsimile: ____________________________________________________________________________

E-Mail: ______________________________________________________________________________

Current Position

Institution: ______________________________________________________________________________________

Since: _______________________________________________________________________________

Appointment: _________________________________________________________________________

Since: ______________________________________________________________________________

Is this a recognized training appointment yes / no

Type of present practice:

£ Predominantly thoracic £ Predominantly cardiovascular £ Both

Professional education

Medical school: _______________________________________________________________________

Surgical training: ______________________________________________________________________

National certification and recognition

Specialty: ___________________________________________________________________________

Year: _______________________________________________________________________________

Authority: ___________________________________________________________________________

Applying for accreditation in:
£ Thoracic surgery £ Cardiovascular surgery £ Both

Enclose a recent photograph and a curriculum vitae

Date: __________________________________

Signature: ______________________________

Note:

For those applying under the "grandfather clause" only Part I has to be completed. However if in their country certifications is not available Part II should also be completed.