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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
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