European Society of Ophthalmology

Educational Grants

You are kindly invited to apply for the 2010 SOE Educational Grants by filling in the below form.

All fields are required.

	Mr. Mrs. Ms.
Family name:
First name:
Hospital / Clinic name:
Hospital / Clinic address:
Supervisor at clinic:
Supervisor's contact details:
City:
Country:	Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Gibraltar Greece Guernsey Hungary Iceland Ireland Isle of Man Italy Jersey Kosovo Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania Russia San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom
E-mail address:
Languages:
	Male Female
Date of Birth:	(dd/mm/yyyy)
No. of years after graduation from medical school:
No. of years of training in ophthalmology:
Hospital / Clinic you wish to visit(1):
City:
Country:	Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Gibraltar Greece Guernsey Hungary Iceland Ireland Isle of Man Italy Jersey Kosovo Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania Russia San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom
Subspecialty you wish to study there:
Hospital / Clinic you wish to visit(2):
City:
Country:	Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Czech Republic Denmark Estonia Faroe Islands Finland France Georgia Germany Gibraltar Greece Guernsey Hungary Iceland Ireland Isle of Man Italy Jersey Kosovo Latvia Liechtenstein Lithuania Luxembourg Macedonia Malta Moldova Monaco Montenegro Netherlands Norway Poland Portugal Romania Russia San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Ukraine United Kingdom
Subspecialty you wish to study there:
Have you already applied for the SOE Educational Grant?
	Yes No
If yes, in which year?
If yes, was your application successful?
	Yes No
Photo:
CV:
	Please do not upload files above 2MB.
	Please wait until confirmation that your application has been correctly filled in.